Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Years Homestead during CMS and state inspections, most recent first.
A resident with multiple comorbidities was prescribed several pain medications, including a new order for morphine, without documented monitoring for adverse side effects or consistent notification of the POA regarding medication changes. Despite facility policy requiring monitoring, there was no documentation of such monitoring after opioid administration, and the resident was later found deceased.
A resident with Parkinson's disease, DM2, and unspecified dementia was observed in a wheelchair and later in a specialized chair with her chin tucked, head turned sharply to the right, fists clenched, and feet not properly positioned on the footrests. The MDS assessment coded no UE impairment in Section GG, and the care plan did not include a specific plan for upper or lower body contractures, although the MDS coordinator stated the resident should have been coded with hands and shoulder impairment.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with epilepsy and dementia did not receive a newly ordered anti-seizure medication for several days after a neurology appointment, while the previous medication was continued without a valid order due to a delay in transcribing and acting on new physician orders. The error was discovered several days later, resulting in delayed administration of the correct medication.
A resident with cognitive and behavioral health diagnoses engaged in inappropriate touching of two other residents, but the facility failed to document the behaviors, update care plans with specific interventions, or implement prevention strategies. Staff interviews revealed inconsistent communication and lack of follow-up, and the social services team was not consistently notified. The affected female resident, who was severely cognitively impaired, had no care plan updates or interventions added after the incident.
The facility did not maintain complete and accurate medical records for two residents after an incident of inappropriate touching. Documentation failed to specify the behaviors, affected individuals, interventions taken, or evidence of required safety checks. Records also lacked details on physician or family notification, immediate assessments, and implementation of safety measures, contrary to facility policy.
The facility failed to ensure medications were properly dated when opened and destroyed when expired, as observed in two medication carts. An LPN found a Trelegy inhaler without an open date, and a QMA found Nystatin and Lidocaine solutions without open dates. Insulin medications for two residents were expired but still present in the cart. Record reviews showed discrepancies in medication management, with some medications lacking open dates and others being expired yet administered.
A resident with severe cognitive decline was abused by a QMA, who pushed the resident against a wall and later across a hallway, causing a fall. The incident was captured on video, showing the QMA's aggressive actions. Despite the resident's care plan addressing cognitive loss and agitation, the abuse occurred in a secured memory care unit. The facility's abuse policy was reviewed, and disciplinary action was taken against the QMA.
A resident with PTSD related to childhood abuse experienced fear due to a male peer entering her room uninvited. Despite reporting the incidents, the facility did not initially implement effective interventions to prevent these occurrences. The resident's care plan lacked trauma-specific goals and interventions, and the facility's trauma-informed care policy was not adequately followed.
The facility failed to maintain infection control measures for oxygen tank tubing for two residents. Oxygen tanks were found on the floor with tubing wrapped around a handrail outside the beauty shop, lacking covers or dates. One resident had COPD with an acute exacerbation, and another was dependent on supplemental oxygen. The DON confirmed the absence of a current facility policy.
The facility failed to report an injury of unknown origin for a resident with dementia. The resident was observed with facial swelling and discoloration on two separate occasions, but no investigation or follow-up was conducted. The DON admitted that the injuries were not reported to the appropriate authorities as required by facility policy.
The facility failed to notify the physician and family timely of a significant change in condition for a resident with Alzheimer's dementia and a recent C. Diff colitis infection. Despite family members reporting symptoms of pain, lethargy, and diarrhea, the facility did not document any assessment or notification to the physician or NP, leading to the resident's hospitalization.
Failure to Monitor for Opioid Side Effects After Dose Increase
Penalty
Summary
The facility failed to monitor for adverse side effects of opioid medications following an increased dose for a resident admitted for rehabilitation after a right hip fracture. The resident had multiple diagnoses, including Parkinson's disease, diabetes mellitus, depression, and stage 3 chronic kidney disease. The resident was prescribed several pain medications, including hydrocodone-acetaminophen, naproxen, oxycodone-acetaminophen, and later, morphine sulfate extended-release. There were no documented orders to monitor for side effects of these pain medications, despite the addition of morphine and the resident's complex medical history. Medication administration records showed frequent administration of multiple pain medications, including the new morphine order. Nursing notes indicated that the resident's power of attorney (POA) and family were not notified of the medication changes, despite facility policy and the resident's moderate cognitive impairment. The POA reported not being informed about the new morphine order and requested that the medication be held, but the resident received the morphine as ordered. Documentation of monitoring for adverse effects was lacking, and there were no notes or assessments between the last pain assessment and the time the resident was found deceased. Interviews with staff revealed inconsistent practices regarding notification of the POA and monitoring for side effects after opioid administration. While some staff stated that monitoring and notification were standard practice, there was no documentation to support that these actions were taken in this case. The facility's policy required monitoring for adverse side effects, but this was not documented or consistently performed for the resident after the opioid dose increase.
Inaccurate Mobility Assessment and Missing Contracture Care Plan
Penalty
Summary
Ensure each resident receives an accurate assessment. The facility failed to assess mobility for 1 of 4 residents reviewed, Resident 35. During observations on 07/30/2025 and 07/31/2025, Resident 35 was seen in a wheelchair and later in a specialized chair with her chin tucked, head sharply turned to the right and out of the headrest, fists clenched, and feet not resting on the footrests during one observation. Her record showed diagnoses of Parkinson's disease, type 2 diabetes, and unspecified dementia. The MDS assessment completed on 07/11/2025 indicated no impairment to the upper extremities in Section GG, and the care plan dated 07/11/2025 did not include a specific plan for contractures of the upper or lower body. In interview, the MDS coordinator stated the resident should have been coded with hands and shoulder impairment on the assessment and that the contractures should also have been included in the care plan.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Follow Physician Orders for Medication Changes
Penalty
Summary
A resident with diagnoses of epilepsy with partial seizures and dementia returned from a neurologist appointment with new physician orders to discontinue Levetiracetam and begin Lacosamide for seizure management. The nurse on duty was responsible for reviewing the progress note, transcribing the new orders onto the physician order form and Medication Administration Record (MAR), and notifying the pharmacy. However, the order to discontinue Levetiracetam and start Lacosamide was not promptly transcribed onto the MAR, resulting in Lacosamide not being administered for several days after the order was written. During this period, Levetiracetam continued to be administered to the resident without a valid physician order, as the discontinuation order was not recognized or acted upon. The error was only identified several days later, after which the medication administration was corrected. The facility did not have a written policy for following physician orders, but nurses were expected to follow such orders as part of their nursing practice.
Failure to Identify and Address Inappropriate Resident Behaviors
Penalty
Summary
The facility failed to identify, document, and implement prevention interventions for inappropriate touching behaviors exhibited by a resident towards other residents. Specifically, a male resident with diagnoses including Parkinson's, dementia, anxiety, and depression, was observed on multiple occasions engaging in inappropriate physical contact with female residents, including hand holding, rubbing shoulders, and placing his hand up another resident's pant leg. Despite these incidents, there was no documentation of specific interventions to prevent recurrence or protect the residents involved, and the care plan lacked details on the types of behaviors to monitor, frequency of monitoring, or behavioral clues to observe. The records show that the resident's care plan was not updated to reflect the inappropriate behaviors or to provide clear guidance to staff on how to address or prevent such incidents. The care plan also did not specify how the resident expressed depression or anxiety, nor did it include interventions tailored to the observed behaviors. Staff interviews revealed that while some staff were aware of the incidents, there was inconsistent communication and documentation regarding the behaviors, and the social services department was not consistently notified or involved in follow-up. Additionally, behavior monitoring flowsheets did not include inappropriate touching as a targeted behavior, and there was no evidence that the psychiatric nurse practitioner was informed of the specific incidents. The female resident involved, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to recall the incident and showed no signs of distress during subsequent assessments. However, her care plan was not updated to address the incident or to include interventions to prevent further occurrences. The facility's policy required close monitoring and individualized care planning for behavioral health issues, but this was not followed in practice, as evidenced by the lack of documentation, care plan updates, and specific interventions after the incidents.
Failure to Maintain Complete and Accurate Medical Records After Resident-to-Resident Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents following incidents of inappropriate touching. For one resident with diagnoses including Parkinson's, dementia, anxiety, and depression, interdisciplinary notes referenced inappropriate behavior but did not specify the nature of the behaviors, who was affected, or what interventions were implemented. There was also no documentation that the resident was placed on 15-minute checks as ordered, nor was there evidence that these checks were completed after the care plan was updated. Additionally, a psychiatric nurse practitioner's note did not reflect awareness of the incident or changes in medication related to observed behaviors. For the second resident, who had Lewy body dementia with psychotic disturbance, major depressive disorder, and anxiety, the records did not document the incident of inappropriate touching, notification to the physician or family, or immediate skin assessment to check for injury. There was also no documentation of how the resident was kept safe following the incident or how interventions were implemented to prevent further occurrences. The hospice visit note referenced the incident but did not specify how the other resident was restricted from entering rooms. Neither resident's clinical record included documentation that the DON and Unit Manager had reviewed the incident to confirm no sexual contact occurred, nor did the records indicate that families were notified or that interventions were put in place to ensure resident safety. The facility's policy requires timely and accurate documentation of all assessments, observations, and services, but this was not followed in these cases.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly dated when opened and destroyed when expired, as observed in two of four medication carts. During an observation, a Trelegy inhaler for a resident was found without a box and no open date, which was acknowledged by an LPN as incorrect. Another observation revealed an open bottle of Nystatin without an open date for a different resident, and a bottle of Lidocaine solution also lacked an open date. Additionally, insulin medications for two residents were found with open dates but had expired, yet were still present in the medication cart. Record reviews for the involved residents showed discrepancies in medication management. One resident with chronic pulmonary disease had a physician's order for Trelegy inhalation, but the medication lacked an open date. Another resident with Alzheimer's disease had no active orders for the Nystatin found. A resident with chronic obstructive pulmonary disease had Lidocaine solution administered without an open date. Two residents with type 2 diabetes mellitus had insulin medications with open dates but expired, yet they were still administered. The facility's medication storage policy, provided by the Director of Nursing, emphasized proper storage and management of medications, which was not adhered to in these instances.
Resident Abuse by Qualified Medication Assistant
Penalty
Summary
The facility failed to protect a resident, identified as Resident 26, from abuse by a Qualified Medication Assistant (QMA 6). Resident 26, who has severe cognitive decline due to dementia, was involved in an incident where QMA 6 pushed him against a wall and later across the hallway, causing him to fall. This incident was captured on video footage, which showed QMA 6's aggressive actions towards Resident 26, who was left on the ground after the altercation. The incident occurred in a secured memory care unit, and another staff member present did not intervene. Resident 26's medical history includes dementia, depression, and muscle weakness, with a Brief Interview for Mental Status score indicating severe cognitive decline. His care plan highlighted cognitive loss and a tendency to become agitated, with interventions to ensure safety and calm communication. Despite these interventions, the incident with QMA 6 occurred, and the behavior sheet for September 2024 showed missing documentation and recorded instances of aggression and anxiety. The Director of Nursing (DON) expressed disbelief upon reviewing the footage, and the Human Resources department noted a gap in the video recordings. Statements from QMA 6 and other staff were collected as part of the investigation. The facility's policy on abuse, neglect, and exploitation was reviewed, which defines abuse as the willful infliction of injury or intimidation resulting in harm or mental anguish. The report indicates that disciplinary action was taken against QMA 6.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to implement interventions to prevent feelings of fear for a resident diagnosed with PTSD related to childhood abuse. The resident expressed feeling overwhelmed since her husband's passing and was triggered by a male peer entering her room uninvited, especially at night. Despite the resident's repeated reports of the peer's unwanted presence, the facility did not initially implement measures such as placing stop signs on the door or other deterrents. The resident requested to lock her door for safety but was denied due to safety concerns. Eventually, the peer was moved to another room, which stopped the visits, but no other solutions were offered to the resident. The resident's care plan, dated June 2024, addressed mood disorders but did not include trauma-specific problems, goals, or interventions. A subsequent care plan in September 2024 included a problem of trauma but lacked specific interventions or triggers. The facility's policy on Trauma Informed Care emphasized minimizing triggers and ensuring emotional and physical safety, but these measures were not effectively implemented for the resident. The resident's records showed no documentation of behaviors related to her trauma, and a trauma questionnaire was not dated, indicating a lack of thorough assessment and response to her trauma-related needs.
Infection Control Deficiency in Oxygen Tank Management
Penalty
Summary
The facility failed to maintain proper infection control measures for oxygen tank tubing for two residents. During an observation, two oxygen tanks were found on the floor in the hallway, with their tubing wrapped around a handrail outside the beauty shop. The tubing lacked covers, bags, or dates indicating when they were placed. Resident 16, diagnosed with chronic obstructive pulmonary disease (COPD), had a physician order for 2 liters per minute of nasal oxygen every shift due to an acute exacerbation. Similarly, Resident 247, dependent on supplemental oxygen, had a physician order for 2 liters per minute of nasal oxygen every shift for COPD. The Director of Nursing (DON) confirmed that residents would leave their oxygen tanks outside the beauty shop and acknowledged the absence of a current facility policy regarding this practice.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for Resident D, who had a diagnosis of dementia with behavioral disturbance. On two separate occasions, the resident was observed with swelling and discoloration on the right side of her face. The first incident was noted on 2/23/24, and the second on 3/23/24. Despite these observations, there was no documentation or investigation into the cause of the injuries, their effect on the resident, or any follow-up for resolution. The resident's family had taken her to the ER for evaluation and treatment after the first incident, but the facility did not report the injuries to the appropriate authorities as required by their policy. In an interview, the DON indicated that staff had assumed the resident had fallen and gotten herself back up in both incidents, although there were no witnesses or reports of falls. The facility's policy mandates reporting all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, immediately to the Administrator and other appropriate agencies. The DON admitted that neither she nor the Administrator reported the injuries, even though the resident was unable to explain how they occurred, and the injuries were suspicious due to their location on the face/head.
Failure to Notify Physician and Family of Significant Change in Condition
Penalty
Summary
The facility failed to notify the physician and family timely of a significant change in condition for Resident D. The resident, who had been admitted following hospitalization for C. Diff colitis, experienced right-sided pain, lethargy, and diarrhea. Despite family members reporting these symptoms to the staff on multiple occasions, the facility did not document any assessment or notification to the physician or nurse practitioner. The resident's condition worsened, and she was eventually hospitalized after the family insisted on her being sent to the hospital for evaluation. Resident D's medical history included Alzheimer's dementia and a recent C. Diff colitis infection. The resident had completed a course of antibiotics and was awaiting discharge. On multiple visits, family members observed the resident in pain and reported it to the staff, who allegedly placed her on the NP list for the next visit. However, there was no documentation of the NP being informed or assessing the resident's pain. The resident was later found lethargic and in a fetal position, with an isolation cart outside her room due to diarrhea, but the family and physician were not notified. Interviews with staff revealed that there was a lack of communication and documentation regarding the resident's symptoms and condition. The QMA and LPN involved did not recall specific details or actions taken to address the resident's complaints. The DON confirmed that there was no documentation of the NP or family being notified about the resident's loose stools and isolation. The facility's policy on notification of changes was not followed, leading to a delay in addressing the resident's significant change in condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chateau Rehabilitation And Healthcare Center | 1.4 mi | ★★★★★ | 20 | 0 |
| Waters Of Fort Wayne Skilled Nursing Facility, The | 1.8 mi | ★★★★★ | 5 | 0 |
| Majestic Care Of New Haven | 3 mi | ★★★★★ | 15 | 0 |
| Celebrate Senior Living Of Fort Wayne | 3.1 mi | ★★★★★ | 12 | 0 |
| Heritage Park | 3.3 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.