Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

ASHTON CREEK HEALTH AND REHABILITATION CENTER

FORT WAYNE, IN · 139 certified beds · Last Life Safety survey July 2, 2025

CMS Certification Number 155798 · first certified July 2012

Ownership

Operated by TLC MANAGEMENT · Non profit - Other

No change of ownership on CMS record since January 1, 2016, when the records begin.

8
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
0
Tags cited more than once
Across separate surveys
2
Inspection & testing records
Of the citations on file

Position within IN

8 citations — more than 23% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

When is the next survey likely?

Well past the typical window (June 2026 to August 2026), and past the point by which nine in ten IN facilities have been surveyed. This facility’s last Life Safety survey was July 2025. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Emergency preparedness

4 of the 8 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

How that compares

Citations on file over three years

Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.

This facility8IN median15National median11
Citations on file over three years, compared
MeasureCitations
This facility8
Median facility in IN15
Median facility nationally11

Survey history

Citations at each Life Safety survey
82023-0702024-0702025-07
Citations at each Life Safety survey
Survey dateCitations
July 11, 20238
July 22, 20240
July 2, 20250

Most-cited tags

Most-cited tags at this facility
K-03241E-00041K-02231E-00291K-07411E-00361E-00131K-03531
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0324Provide properly protected cooking facilities.12023-07-11
E-0004Develop and maintain an Emergency Preparedness Program (EP).12023-07-11
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.12023-07-11
E-0029Develop a communication plan.12023-07-11
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.12023-07-11
E-0036Establish emergency prep training and testing.12023-07-11
E-0013Develop Emergency Preparedness policies and procedures.12023-07-11
K-0353Inspect, test, and maintain automatic sprinkler systems.12023-07-11

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 4
  • Smoke Deficiencies 2
  • Egress Deficiencies 1
  • Miscellaneous Deficiencies 1
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies4
Smoke Deficiencies2
Egress Deficiencies1
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

July 11, 2023 — 8 citations

Citations issued on July 11, 2023
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (August 19, 2023)
E-0013Develop Emergency Preparedness policies and procedures.Deficient, Provider has date of correction (August 19, 2023)
E-0029Develop a communication plan.Deficient, Provider has date of correction (August 19, 2023)
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (August 19, 2023)
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.Deficient, Provider has date of correction (August 19, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (August 19, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (August 19, 2023)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (October 2, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.