Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Sage Bluff Health And Rehab Center during CMS and state inspections, most recent first.
The facility failed to maintain adequate hot water and to consistently monitor dish machine temperatures needed for kitchen sanitation, affecting meals prepared for most residents. A dietary staff member responsible for dishwashing reported ongoing hot water problems, used stove‑boiled water mixed with cold water for washing and sanitizing dishes, and did not measure final water temperatures or receive clear guidance for water heater failures. Review of dish machine temperature logs showed multiple missing entries despite policy requiring readings at each meal. The ADM and Dietary Manager confirmed there was no corporate policy for handling hot water failures, acknowledged that staff relied on improvised methods such as heating water on the stove or capturing hot water from the dish machine, and could not explain the missing log entries. The Maintenance Director reported that the water heater serving the kitchen and laundry had malfunctioned for months, required replacement per a contractor, and was awaiting corporate action, while existing policies required specific water temperatures and frequent monitoring that were not consistently followed.
A resident with a history of falls and multiple medical conditions sustained a wrist fracture after falling during an outside appointment where no staff accompanied her, despite a care plan intervention requiring staff accompaniment. The resident was again sent to a follow-up appointment without staff present, and facility staff interviews revealed a lack of communication and awareness regarding the need for supervision during appointments.
A resident was subjected to condescending and verbally abusive remarks by a QMA, including being called a liar and refused assistance with personal care. The resident expressed fear for her safety, was observed crying, and ultimately left the facility against medical advice. Witnesses, including another resident and staff, confirmed the QMA's threatening behavior and refusal to help, which resulted in the resident injuring herself while dressing.
A resident with a stage 4 sacral pressure ulcer, fully dependent on staff for mobility, did not receive daily wound care as ordered on two consecutive days. The resident, who was cognitively intact and admitted for wound care, reported missed dressing changes, and facility records confirmed the omission despite clear physician orders and facility policy.
A resident with cognitive impairment and dependence on renal dialysis eloped from the facility and was found outside after a door alarm was triggered. The resident was assisted back inside, but the incident was not reported to the state health department until two days later, violating the facility's policy of reporting within 24 hours.
A facility failed to attempt non-pharmacological interventions before administering PRN pain medication to a resident with dementia and other conditions. Despite having a care plan and a policy requiring such interventions, the facility did not document any attempts before administering medication on multiple occasions. The DON confirmed that the lack of documentation indicated non-compliance with the policy.
A resident with multiple health issues, including dependence on renal dialysis, experienced incomplete communication between the nursing home and dialysis center. Documentation showed repeated failures to fill out necessary sections of communication forms by both parties, affecting the resident's care. The facility's policy required thorough communication, which was not followed.
A resident with dementia and depression repeatedly grabbed another nonverbal resident's wrist and thigh without staff intervention or documentation. The behavior was not recognized as problematic, and the affected resident, who had mobility and skin integrity issues, was unable to move away independently. The facility's behavior management policy was not followed, contributing to the deficiency.
A resident with severe cognitive impairment was physically abused by a staff member during repositioning in a wheelchair. The staff member retaliated after being struck by the resident, violating the facility's abuse policy. The incident was not reported immediately, highlighting a deficiency in the facility's care practices.
A resident with severe cognitive impairment and a history of trauma was involved in an altercation with staff during repositioning, resulting in the resident being struck by a staff member. The incident was not reported immediately by the witnessing staff, leading to a delay in notifying authorities.
A facility failed to provide trauma-informed care for a resident with a history of trauma and abuse, as the care plan lacked specific triggers and approaches to prevent re-traumatization. The resident's guardian expressed concerns about safety and visitor restrictions, which were not adequately communicated to staff. Nursing staff were unaware of the resident's specific needs, and the facility lacked a specific policy for trauma-informed care.
Failure to Maintain Hot Water and Monitor Dish Machine Temperatures for Kitchen Sanitation
Penalty
Summary
The deficiency involves the facility’s failure to maintain appropriate hot water temperatures and to consistently monitor dish machine temperatures needed for kitchen sanitation, affecting meals prepared for 45 of 47 residents. A dietary staff member responsible for dishwashing reported that he was supposed to complete the dishwasher temperature log at each meal but was unsure how to determine the readings and did not know why the log was not current. He stated that water at the hand sink was usually only cool and that the dish sinks had cold water due to a water heater problem that had been ongoing for several months. To compensate, he boiled water on the stove and poured it into the sink, mixing it with cold water for washing and sanitizing dishes and preparing sanitizer water for wiping surfaces, but he did not measure the final water temperature and had not been given clear policy guidance on how to proceed during a water heater failure. Record review of the High Temperature Dish Machine log showed multiple missing wash and rinse temperature entries across numerous meal times, despite policy requiring temperatures to be recorded at breakfast, noon, and evening meals. The Assistant Dietary Manager stated there was no corporate policy on handling hot water failure, confirmed that water heater problems had persisted for about seven months, and acknowledged that staff heated water on the stove for soaking and sanitizing because the sinks did not provide sufficiently hot water, while also being unaware of any concrete plan to resolve the hot water issue or the reason for missing log entries. The Dietary Manager similarly reported there was no company policy for water temperature failure and described an informal practice of using a pot placed in the dish machine to capture hot water for sinks, while stating that dish machine temperatures should be logged with the first load each morning. The Maintenance Director reported that the water heater serving the kitchen and laundry had been replaced and then began malfunctioning months later, that a contractor had recommended replacement, and that quotes had been submitted to corporate without a replacement date established. Existing written policies required verification and frequent monitoring of dish machine temperatures and specified minimum temperatures for manual dishwashing and sanitizer preparation, which were not consistently followed under the prolonged hot water failure.
Failure to Implement Fall Prevention Interventions During Resident Appointments
Penalty
Summary
A deficiency occurred when the facility failed to ensure that fall interventions were followed for a resident identified as being at risk for falls. The resident, who had diagnoses including congestive heart disease, muscle weakness, and post-traumatic stress disorder, returned from an outside appointment and reported to staff that she had fallen in the bathroom during the appointment, resulting in an open and closed distal fracture of her left wrist. Although the care plan, updated after the incident, specified that staff were to accompany the resident to all outside appointments, documentation and interviews confirmed that this intervention was not implemented for a subsequent appointment. Specifically, the resident was transported to a follow-up appointment by the Maintenance Director without any staff accompanying her, contrary to the care plan intervention. Interviews with facility staff, including the Administrator, Maintenance Director, and LPNs, revealed a lack of communication and awareness regarding the requirement for staff accompaniment. The Maintenance Director stated he was not notified that the resident required accompaniment until after the second appointment had already occurred. The facility's fall prevention policy required that new interventions be implemented and care plans updated to prevent further falls, but the intervention to accompany the resident was not followed.
Verbal Abuse and Intimidation by QMA Toward Resident
Penalty
Summary
A resident reported experiencing condescending and verbally abusive remarks from a Qualified Medical Assistant (QMA). The resident stated she overheard the QMA accuse her of lying and expressed fear of retaliation if she reported the behavior. Documentation included a written statement from the QMA describing the resident as someone who complains frequently and tells stories, as well as an incident where the QMA allegedly pulled a curtain aggressively in the resident's room. The resident expressed fear for her safety and indicated she might call the police after contacting her daughter. Following these events, the resident left the facility against medical advice due to fear after allegations of verbal abuse, and a report was made to adult protective services. Multiple staff and another resident corroborated the account, stating they witnessed the QMA loudly calling the resident a liar, refusing to assist her with personal care, and behaving in a threatening manner. The resident was observed crying and visibly distressed, and another resident confirmed the QMA's refusal to help and the resident's subsequent injury while attempting to dress herself. Facility policy defines verbal abuse as the use of disparaging or derogatory language within hearing distance of residents, regardless of their ability to comprehend, and includes intimidation or actions causing mental anguish.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with a stage 4 sacral pressure ulcer, who was completely dependent on caregivers for mobility, did not receive wound care as ordered. The resident, who was cognitively intact and residing at the facility specifically for wound care, reported not receiving wound care on a specified Friday, with the last dressing change occurring a week prior. Review of physician orders indicated that the wound was to be cleansed and packed daily and as needed, but documentation on the medication administration record confirmed that wound care was not completed on two consecutive days. Facility policy required dressings to be changed according to orders unless specific indications for removal were present.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an elopement incident involving Resident 199 in a timely manner. Resident 199, who has a cognitive communication deficit, muscle weakness, and is dependent on renal dialysis, was found outside the facility on the sidewalk after the 200 hall door alarm was triggered. The resident, who has a BIMS score of 10 indicating moderate impairment, stated he was attempting to find his sister. Staff immediately assisted the resident back into the facility, provided snacks, and placed him in a visible area. However, the incident was not reported to the Indiana State Department of Health until two days later, contrary to the facility's policy requiring incidents to be reported within 24 hours.
Failure to Attempt Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted before administering PRN pain medication to a resident diagnosed with unspecified dementia and mild psychotic disturbance. The resident had a physician's order for Percocet to be administered for severe pain, but there were no orders indicating that non-pharmacological interventions should be attempted first. The care plan for the resident, which was last edited in October 2024, did not include personalized non-pharmacological interventions, despite the resident's diagnoses of colon cancer and fibromyalgia. The Medication Administration Record showed multiple instances in August, September, and October 2024 where PRN pain medication was administered without documentation of attempted non-pharmacological interventions. The Director of Nursing confirmed that staff are required to attempt and document non-pharmacological interventions, but acknowledged that if there is no documentation, it indicates that these attempts were not made. The facility's Pain Management policy, dated August 2024, mandates that non-pharmacological interventions be attempted prior to administering PRN pain medications, but this was not adhered to in the case of the resident.
Incomplete Communication with Dialysis Center for Resident
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center for a resident who required dialysis services. The resident, who had diagnoses including dependence on renal dialysis, hepatic encephalopathy, kidney failure, cirrhosis of the liver, and general weakness, had specific orders for dialysis on certain days, a renal diet, and regular checks of their fistula. However, the communication between the nursing home and the dialysis center was incomplete on multiple occasions, as evidenced by the review of the dialysis communication book. The documentation revealed numerous instances where sections of the communication forms were left blank by both the nursing home and the dialysis center. For example, the nursing home failed to complete sections related to the resident's mental status, significant alerts, dietary needs, and whether the dialysis chair was cleaned. Similarly, the dialysis center often did not fill out sections regarding fluid removal, discharge times, weights, vital signs, and other critical information. This lack of thorough documentation persisted over several dates, indicating a pattern of incomplete communication. In an interview, the Director of Nursing and the Regional Nurse Consultant acknowledged that the forms should have been fully completed. They also noted that when the dialysis center did not return completed forms, the facility should have contacted the center to request the missing information and documented this request in the resident's chart. The facility's policy on hemodialysis care emphasized the importance of communication between the dialysis provider and facility staff before and after each treatment, which was not adhered to in this case.
Failure to Manage Resident Behaviors
Penalty
Summary
The facility failed to manage behaviors for a resident diagnosed with dementia and depression, who displayed inappropriate physical interactions with another resident. During observations, the resident was seen grabbing the wrist and inner thigh of another resident multiple times without intervention from staff. The behavior was not documented, and staff did not initially recognize it as a behavior requiring management. The resident claimed to be assisting the other resident with mobility, showing pride in perceived progress, while the other resident, who was mainly nonverbal and unable to move independently, did not consent to the physical contact. The affected resident, who was nonverbal and had limited mobility, was unable to move away from the situation independently. The resident's care plan included issues with mobility and skin integrity, but there was no documentation of the bruising observed on the resident's wrist, which was attributed to a blood test conducted weeks prior. The staff's failure to document and address the behavior as a potential issue contributed to the deficiency. Interviews with the Director of Nursing and the Regional Nurse Consultant revealed that the behavior was overlooked as harmless handholding, and no behavior tracking was in place for the resident displaying the behavior. The facility's policy on behavior management required assessment and tracking of behaviors impacting residents' quality of life, which was not followed in this case.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, as evidenced by an incident involving Resident Q. The incident occurred when Employee 5, while assisting in repositioning Resident Q in her wheelchair, was struck in the face by the resident. In response, Employee 5 retaliated by slapping Resident Q on the cheek. This action was witnessed by Employee 2, who did not report the incident immediately, leading to a delay in addressing the abuse. Resident Q, who has diagnoses including brain damage due to trauma, major depressive disorder, and dependence on a wheelchair, was assessed to have severely impaired cognition. Despite her cognitive impairments, she was noted to have no behaviors, moods, or signs of delirium prior to the incident. Her care plan included interventions for managing behaviors such as striking others during care, which were not effectively implemented during the incident. The facility's policy mandates immediate reporting of abuse, which was not adhered to by Employee 2, who only reported the incident later in the evening. This delay in reporting and the subsequent failure to protect Resident Q from abuse constituted a deficiency in the facility's care practices.
Delayed Reporting of Resident Abuse Incident
Penalty
Summary
The facility failed to report timely physical abuse of a resident, identified as Resident Q, who was involved in an altercation with a staff member. On the morning of the incident, Resident Q, who had diagnoses including brain damage due to trauma and major depressive disorder, was being repositioned in her wheelchair by three employees. During this process, Resident Q became combative and struck one of the employees, Employee 5, in the face. In response, Employee 5 retaliated by striking Resident Q in the face with an open hand. Despite witnessing the incident, Employees 2 and 3 did not report the abuse immediately. Employee 2 later reported the incident to the Administrator after leaving the facility that evening. Resident Q's medical history included severely impaired cognition and dependence on staff for most activities of daily living. The resident's care plan noted behaviors such as striking others during care and a history of trauma and abuse. Despite these considerations, the staff involved did not adhere to the facility's policy requiring immediate reporting of abuse. The incident was eventually reported to the Indiana Department of Health, but not until later that evening, indicating a delay in the reporting process.
Failure to Provide Trauma-Informed Care for Resident with History of Abuse
Penalty
Summary
The facility failed to provide trauma-informed care for Resident Q, who has a history of trauma and abuse, resulting in a deficiency. Resident Q's care plan did not identify specific triggers or implement resident-specific approaches to prevent re-traumatization. The care plan included general interventions such as administering medications, allowing the resident to vent feelings, and attempting to reduce stressors, but lacked detailed strategies to address her past trauma. Additionally, the care plan did not include measures to ensure the resident's safety from potential abusers, despite the guardian's concerns and instructions regarding visitor restrictions. Interviews with the resident's guardian and nursing staff revealed gaps in communication and awareness of the resident's needs. The guardian expressed concerns about the resident's safety, citing an incident where a family member not on the approved visitor list was allowed into the facility without notification. Furthermore, the guardian reported an incident where a staff member allegedly hit the resident, which was not communicated to her promptly. Nursing staff were unaware of the resident's specific triggers and visitor restrictions, indicating a lack of training or information dissemination regarding trauma-informed care. The facility's Director of Nursing acknowledged the absence of a specific policy for trauma-informed care, relying instead on a general social services policy.
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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) |
|---|---|---|---|---|
| Coventry Meadows | 0.1 mi | ★★★★★ | 8 | 0 |
| Majestic Care Of Jefferson Pointe | 1.6 mi | ★★★★★ | 18 | 1 |
| Englewood Health & Rehabilitation Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Fort Wayne | 5.3 mi | ★★★★★ | 2 | 0 |
| Majestic Care Of West Allen | 5.6 mi | ★★★★★ | 10 | 1 |
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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.