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Complaint Investigation

Lutheran Life Villages

Inspection Date: October 20, 2025
Total Violations 1
Facility ID 155586
Location FORT WAYNE, IN
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Inspection Findings

F-Tag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

dated 9/22/25, indicated the resident had potential to become verbally aggressive. Interventions included analyzation and documentation of circumstances, triggers and actions known to de-escalate aggressive behavior, assessment of Resident A's coping skills, intervention before agitation escalates and support system and a psychiatric consultation. Resident A's care plan did not indicate the resident should be monitored when their spouse was present. The care plan did not indicate staff members were directed to intervene and safeguard the resident if needed.The care plan did not indicate the resident's spouse had given them medication.The care plan did not indicate the resident's spouse had fed the resident.The care plan did not indicate the resident's spouse had repositioned the resident.The care plan did not indicate the resident's spouse had made contact with the resident's face.A unit assignment sheet for direct care staff, (resident profile) dated 8/28/25, provided various categories of care areas for each resident. Some residents had listed behaviors such as anxiety at times and combativeness with care. The resident profile indicated Resident A did not have behaviors. Some residents had listed safety concerns such as fall risk or appropriate footwear. The resident profile indicated Resident A did not have safety issues as the safety category for Resident A was blank.In an interview, on 10/20/25 at 2:07 PM, Licensed Practical Nurse (LPN) 2 indicated they had been verbally instructed to monitor Resident A when their spouse was present. LPN 2 indicated Resident A's spouse resided at the facility's independent living unit and visited Resident A frequently. LPN 2 indicated Resident A's spouse would get frustrated when the resident got aggressive with them. LPN 2 indicated Resident A's family interactions among the daughter and the spouse were tense.

LPN 2 indicated safety precautions should be included in the residents' care plan. LPN 2 indicated safety precautions should be included on the resident profile assignment sheets.In an interview, on 10/20/25 at 3:05 PM, the Administrator indicated the staff had been given verbal instructions to monitor Resident A's interactions with their spouse. The Administrator indicated they had been aware of Resident A's spouse giving the resident medication. The Administrator indicated social services did not have any information due to the Administrator having handled all aspects of the situation and spoke with Resident A's daughter numerous times. The Administrator indicated they were aware Resident A's care plan and resident profile assignment sheets had not been updated to reflect the recent interactions between Resident A and their spouse. The Administrator indicated they provided verbal education as the staff do not look at their assignment sheets. The Administrator indicated they would provide staff education records. An in-service attendance log, dated 10/9/25, and provided by email from the Administrator on 10/21/25 at 7:32 AM was reviewed. The log indicated verbal education had been provided to staff to monitor Resident A for adverse events when their spouse visits. The staff members were directed to intervene and safeguard the resident if needed.A current facility policy, dated 4/1/99 and revised on 12/15/22, indicated the facility would identify, correct and intervene in situations where resident abuse is more likely to occur.This citation is related to Intake 26395753.1-27(a)(b)

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📋 Inspection Summary

LUTHERAN LIFE VILLAGES in FORT WAYNE, IN inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FORT WAYNE, IN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LUTHERAN LIFE VILLAGES or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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