Inspection Reports for Lutheran Life Villages
9802 COLDWATER ROAD, FORT WAYNE, IN, 46825
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 19, 2025, was a complaint investigation with no deficiencies cited. Earlier inspections showed a mixed record, with some deficiencies noted in resident care and life safety issues, such as restricted egress through magnetically locked exit doors and incomplete electrical equipment documentation in April 2025, as well as medication and monitoring concerns in early 2025 and 2024. Complaint investigations were mostly unsubstantiated or found no related deficiencies, though a substantiated complaint in late 2022 involved inadequate grievance investigations and documentation, which the facility addressed with training and audits. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The trend suggests some improvement in compliance with life safety and care requirements in the most recent inspections.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
82 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00461610.
Complaint Details
Complaint IN00461610 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00461610.
Report Facts
Census Bed Type: 82
Census Bed Type - SNF/NF: 47
Census Bed Type - SNF: 35
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 40
Inspection Report
Re-Inspection
Census: 81
Capacity: 84
Deficiencies: 0
Date: May 13, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/16/25 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR survey, Lutheran Life Villages was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 81
Capacity: 84
Deficiencies: 2
Date: Apr 16, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included two exit doors that were magnetically locked and only accessible by staff key fobs, restricting egress, and incomplete documentation of electrical equipment testing for leakage current and touch current.
Deficiencies (2)
Failed to ensure the means of egress through 2 of 15 exit doors were readily accessible; doors were magnetically locked and could only be opened with staff key fobs.
Failed to maintain complete documentation of inspections for Patient-Care Related Electrical Equipment including leakage current and touch current testing.
Report Facts
Facility capacity: 84
Census: 81
Exit doors affected: 2
Total exit doors: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Souder | Maintenance Director | Interviewed regarding exit door egress and electrical equipment testing deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Renewal
Census: 83
Capacity: 83
Deficiencies: 3
Date: Mar 19, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on March 13, 14, 17, 18 and 19, 2025.
Findings
The facility was found deficient in three areas: failure to follow physician orders for lab monitoring for one resident, failure to properly monitor and maintain a vascular access device for one resident, and failure to follow pharmacy recommendations for medication discontinuation for one resident. Corrective actions and monitoring plans were implemented for each deficiency.
Deficiencies (3)
Failed to ensure physician orders were followed regarding a laboratory blood draw for Resident 8.
Failed to ensure vascular access device was monitored and maintained for Resident 52.
Failed to ensure pharmacy recommendations were followed through for Resident 22 regarding medication discontinuation.
Report Facts
Census: 83
Total Capacity: 83
Medicare Census: 4
Medicaid Census: 37
Other Payor Census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matt Souder | Administrator | Signed the report |
| Director of Nursing | Interviewed regarding deficiencies and corrective actions for Residents 8, 22, and 52 | |
| Registered Nurse 2 | Registered Nurse | Observed and interviewed regarding PICC line dressing changes for Resident 52 |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, IV fluid administration, and pharmacy drug regimen review at Lutheran Life Villages nursing home.
Findings
The facility failed to ensure physician orders were followed for laboratory blood draws, failed to properly monitor and maintain vascular access devices for IV fluids, and failed to follow pharmacy recommendations for medication discontinuation. Deficiencies were noted in documentation, dressing changes, and adherence to policies.
Deficiencies (3)
Failed to ensure physician orders were followed regarding a laboratory blood draw for Resident 8.
Failed to ensure vascular access device was monitored and maintained for Resident 52, including missing dressing dates, lack of arm circumference measurement, and improper Stat Lock handling.
Failed to ensure pharmacy recommendations were followed for Resident 22 regarding discontinuation of Methocarbamol.
Report Facts
Resident count reviewed: 5
Medication dosage: 150
Medication dosage: 250
Upper arm circumference: 26
External catheter length: 0
External catheter length: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding missed lab draw for Resident 8, PICC line dressing procedures, and medication discontinuation |
| RN 2 | Registered Nurse | Observed flushing and changing Resident 52's PICC line dressing |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443413.
Complaint Details
Complaint IN00443413 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00443413 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 81
Census Payor Type Medicare: 8
Census Payor Type Medicaid: 37
Census Payor Type Other: 36
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: May 8, 2024
Visit Reason
This visit was for the investigation of complaints IN00432549 and IN00432620.
Complaint Details
Complaint IN00432549 - No deficiencies related to the allegations are cited. Complaint IN00432620 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited for either complaint. Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of the complaints.
Report Facts
Census Bed Type: 82
Census Bed Type SNF/NF: 35
Census Bed Type SNF: 47
Census Payor Type Medicare: 12
Census Payor Type Medicaid: 38
Census Payor Type Other: 32
Inspection Report
Life Safety
Census: 75
Capacity: 84
Deficiencies: 0
Date: Mar 12, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas.
Report Facts
Facility capacity: 84
Census: 75
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was conducted.
Findings
Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Routine
Deficiencies: 3
Date: Feb 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including medication management, pressure ulcer care, and respiratory care.
Findings
The facility failed to ensure proper monitoring and physician orders for an implanted intrathecal morphine pump for one resident, failed to provide pressure ulcer care according to physician orders for another resident, and failed to ensure safe and appropriate respiratory care including proper oxygen tubing storage and incorporation into the care plan for a third resident.
Deficiencies (3)
Failed to ensure an implanted intrathecal pump morphine delivery system was monitored and included in physician orders for Resident 8.
Failed to provide pressure ulcer care according to physician's orders for Resident 48, including use of betadine and timely pharmacy delivery.
Failed to ensure oxygen was addressed in the plan of care and oxygen tubing was contained when not in use for Resident 75.
Report Facts
Medication volume: 40
Morphine concentration: 9
Infusion rate: 0.2
Oxygen flow rate: 2
BIMS score: 15
BIMS score: 15
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding intrathecal pump medication orders and oxygen care |
| RN 10 | Registered Nurse | Observed and interviewed regarding pressure ulcer dressing and betadine use |
| LPN 11 | Licensed Practical Nurse | Interviewed regarding oxygen tubing storage and equipment use |
Inspection Report
Annual Inspection
Census: 80
Capacity: 80
Deficiencies: 3
Date: Feb 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days in February 2024.
Findings
The facility was found deficient in monitoring an implanted intrathecal morphine pump for one resident, providing pressure ulcer care according to physician orders for another resident, and ensuring oxygen therapy was properly addressed in care plans and tubing was contained when not in use for a third resident. Plans of correction and staff training were implemented for each deficiency.
Deficiencies (3)
Failed to ensure an implanted intrathecal pump morphine delivery system was monitored for 1 of 3 residents reviewed (Resident 8).
Failed to ensure pressure ulcer care was provided according to physician's orders for 1 of 2 residents reviewed (Resident 48).
Failed to ensure oxygen was addressed in the plan of care and tubing was contained when not in use for 1 of 5 residents reviewed (Resident 75).
Report Facts
Survey dates: 5
Census Bed Type - SNF: 34
Census Bed Type - SNF/NF: 46
Total Census: 80
Medicare Census: 10
Medicaid Census: 38
Other Payor Census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Douglas | Administrator | Signed the report and involved in plan of correction |
| Director of Nursing | Director of Nursing | Reviewed deficiencies, implemented corrective actions, and conducted staff training related to intrathecal pump monitoring, wound treatment, and oxygen therapy |
| Registered Nurse 10 | Registered Nurse | Observed during pressure ulcer dressing change and provided information about wound care |
| Licensed Practical Nurse 11 | Licensed Practical Nurse | Interviewed regarding oxygen tubing storage and use |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Dec 14, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00422399.
Complaint Details
Complaint IN00422399 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 47
Census Bed Type - SNF: 34
Census Total: 81
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 39
Census Payor Type - Other: 31
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00416400 and IN00417179 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints IN00416400 and IN00417179 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in Complaints IN00416400 and IN00417179 were cited. The facility was found to be in compliance with relevant regulations including 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census: 82
SNF/NF beds: 46
SNF beds: 36
Medicare residents: 5
Medicaid residents: 36
Other payor residents: 41
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Aug 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413712.
Complaint Details
Investigation of Complaint IN00413712 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in Complaint IN00413712 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 80
Census Payor Type: 80
Census SNF/NF: 46
Census SNF: 34
Census Medicare: 17
Census Medicaid: 38
Census Other: 25
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Jul 24, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00412807.
Complaint Details
Investigation of Complaint IN00412807 with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations are cited. Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00412807.
Report Facts
Census Bed Type: 81
Census Payor Type: 81
SNF/NF beds: 46
SNF beds: 35
Medicare residents: 15
Medicaid residents: 38
Other payor residents: 28
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409062.
Complaint Details
Complaint IN00409062 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 47
Census Bed Type - SNF: 32
Census Total: 79
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 40
Census Payor Type - Other: 31
Census Payor Type - Total: 79
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 1, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on April 14, 2023.
Findings
Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 76
Capacity: 84
Deficiencies: 0
Date: Apr 24, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a fully sprinklered one-story building with a fire alarm system and smoke detection in required areas.
Report Facts
Facility capacity: 84
Census: 76
Inspection Report
Annual Inspection
Census: 81
Capacity: 81
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from April 10 to April 13, 2023.
Findings
The facility failed to implement intervention strategies for agitation and refusal of care for one resident (Resident 74) with behavioral issues. The resident exhibited multiple behaviors including hitting staff, refusal of care, and agitation, which were not addressed in the care plan or with psychiatric evaluation. The facility subsequently updated care plans, provided staff training, and implemented audits to ensure compliance.
Deficiencies (1)
Failure to implement intervention strategies for agitation and refusal of care for Resident 74.
Report Facts
Census Bed Type - SNF/NF: 46
Census Bed Type - SNF: 35
Total Census: 81
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Douglas | Administrator | Named as Administrator responsible for oversight and plan of correction |
| LPN 2 | Licensed Practical Nurse who provided information about staff awareness of resident behaviors | |
| Social Service Director | Director of Social Services | Responsible for behavioral documentation, monitoring, and updating care plans |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement intervention strategies for agitation and refusal of care for a resident with behavioral issues.
Complaint Details
The complaint investigation found that the facility did not adequately address behavioral issues of Resident 74, including refusal of care, hitting staff, pushing staff, and yelling. The resident was not evaluated psychiatrically despite exhibiting these behaviors. Staff interviews indicated awareness of behaviors but inadequate care planning and intervention.
Findings
The facility failed to provide appropriate treatment and services to a resident diagnosed with mental disorders and behavioral issues, including agitation and refusal of care. The resident's care plan did not address exhibited behaviors, and the resident did not receive a psychiatric evaluation despite exhibiting behaviors such as hitting, pushing, yelling, and care rejection.
Deficiencies (1)
Failed to implement intervention strategies for agitation and refusal of care for 1 resident reviewed for behavioral services.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Indicated staff was made aware of new resident behaviors during daily morning meetings and that the Social Service Director was responsible for behavioral documentation and monitoring. | |
| Administrator | Indicated the Social Service Director updated care plans for behavioral issues and that Resident 74 should have received a psychiatric evaluation. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402855.
Complaint Details
Complaint IN00402855 was substantiated, but no deficiencies related to the allegations were cited.
Findings
The complaint IN00402855 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 45
Census Bed Type - SNF: 33
Census Bed Type - Total: 78
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 38
Census Payor Type - Other: 31
Census Payor Type - Total: 78
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Date: Dec 6, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00393346 and IN00395272 at Lutheran Life Villages.
Complaint Details
Complaint IN00393346 was unsubstantiated due to lack of evidence. Complaint IN00395272 was substantiated. The complaint involved allegations that staff yelled at Resident H, threw her things, and said her room was messy. Observations confirmed Resident H's room was messy with a foul odor and soiled items. Grievance forms lacked documentation of investigation and resolution. Staff were unable to provide evidence of abuse determination. Facility policy on grievances was reviewed and corrective actions including training and audits were implemented.
Findings
Complaint IN00393346 was unsubstantiated due to lack of evidence. Complaint IN00395272 was substantiated with federal/state deficiencies cited related to grievances. The facility failed to ensure grievances were thoroughly investigated, documented, and appropriate corrective actions were taken for one resident (Resident H).
Deficiencies (1)
Failure to ensure grievances were thoroughly investigated, contained required documentation, and appropriate corrective actions were taken for Resident H.
Report Facts
Census: 83
SNF/NF beds: 47
SNF beds: 36
Medicare residents: 14
Medicaid residents: 38
Other residents: 31
Deficiency completion date: Dec 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Douglas | Administrator | Signed the report and involved in review of grievance process |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 2, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00395272 completed on December 2, 2022.
Complaint Details
Investigation of Complaint IN00395272; paper compliance review found facility in compliance.
Findings
Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: Sep 12, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00389398.
Complaint Details
Complaint IN00389398 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 78
SNF/NF beds: 46
SNF beds: 32
Medicare residents: 13
Medicaid residents: 37
Other payor residents: 28
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