Inspection Reports for Cedarhurst of Fort Wayne
9210 MAYSVILLE ROAD, FORT WAYNE, IN, 46815
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 18, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of some deficiencies primarily involving documentation issues such as unsigned service plans and communication lapses, including a substantiated complaint in February 2025 about delayed notification to a physician and family after a resident’s fall. Prior reports also cited medication errors and several administrative and procedural deficiencies, including incomplete transfer documentation, abuse reporting delays, and staffing certification gaps, but no fines or enforcement actions were listed in the available reports. Most complaint investigations were unsubstantiated or found no deficiencies, with a few substantiated complaints that did not result in enforcement actions. The facility’s recent inspections suggest some improvement in compliance, particularly with no deficiencies noted in the latest review.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
83 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460591.
Complaint Details
Investigation of Complaint IN00460591 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00460591 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
This visit was for a State Residential Licensure Survey which included complaint IN00455049. The complaint investigation was conducted to assess allegations related to the facility.
Complaint Details
Complaint IN00455049 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. However, the facility failed to ensure current, signed Individualized Service Plans (ISPs) for 5 of 5 residents reviewed. The ISPs were not signed by the residents or their representatives, and documentation of review was not available.
Deficiencies (1)
Facility failed to ensure a current, signed service plan was completed for 5 of 5 residents reviewed (Residents 1, 2, 3, 6, and 7).
Report Facts
Residents with unsigned service plans: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Cerutti | Ed In Training | Signed as Laboratory Director's or Provider/Supplier Representative's signature on the report. |
| Director of Nursing (DON) | Interviewed on 3/18/25 regarding ISP signing practices and facility compliance. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00453897.
Complaint Details
Investigation of Complaint IN00453897 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Feb 14, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452627 regarding allegations of failure to notify physician and family following a significant change in condition for Resident Z.
Complaint Details
Complaint IN00452627 alleged Resident Z had a fall resulting in a femur fracture and the family was not immediately notified. The complaint was substantiated with state deficiencies cited.
Findings
The facility failed to ensure timely notification to the physician and family after Resident Z experienced a fall resulting in a femur fracture. Staff delayed notifying hospice and family from the time pain was first observed until hospice was contacted at 11:30 a.m. The investigation revealed gaps in communication and notification procedures.
Deficiencies (1)
Failed to ensure the physician and family were notified following a significant change in condition for Resident Z.
Report Facts
Residential Census: 78
Date of incident: Jan 9, 2025
Date of survey: Feb 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Cerutti | AIT | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00449267.
Complaint Details
Complaint IN00449267 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Cedarhurst of Fort Wayne was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00449267.
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00443514.
Complaint Details
Complaint IN00443514 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Cedarhurst of Fort Wayne was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00443514.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00438817 and IN00439651 at Cedarhurst of Fort Wayne.
Complaint Details
Investigation of Complaints IN00438817 and IN00439651 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No Federal or State deficiencies related to the allegations in complaints IN00438817 and IN00439651 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: May 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434368 regarding medication errors at the facility.
Complaint Details
Complaint IN00434368 was substantiated with state deficiencies cited related to medication errors involving Resident B's Fentanyl patch application and removal.
Findings
The facility failed to ensure residents were free of medication errors for 1 of 2 residents reviewed (Resident B), specifically related to improper application and removal of Fentanyl patches, resulting in multiple patches being applied simultaneously.
Deficiencies (1)
Failed to ensure residents were free of medication error related to Fentanyl patch application and removal for Resident B.
Report Facts
Residential Census: 78
Deficiency completion date: Jul 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 2 | Qualified Medication Aide | Applied Fentanyl patch on 5/8/24 and involved in medication error |
| QMA 3 | Qualified Medication Aide | Applied Fentanyl patch on 5/11/24 and involved in medication error |
| QMA 4 | Qualified Medication Aide | Removed Fentanyl patches on 5/11/24 after resident was found with multiple patches |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding patch application procedures and notification of DON |
| DON | Director of Nursing | Provided oversight and instructions regarding patch application and removal |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 13
Date: May 2, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00431428.
Complaint Details
Complaint IN00431428 - State deficiencies related to the allegations are cited at R0357.
Findings
The facility was found deficient in multiple areas including incomplete transfer documentation, failure to protect a resident from physical abuse, untimely reporting of abuse allegations, lack of CPR certified staff on duty at all times, incomplete semi-annual evaluations, unsigned service plans, missing physician medication orders for a resident self-administering medications, kitchen sanitation issues, incomplete pharmacy reviews, incomplete annual health statements, and inadequate documentation following a resident's death.
Deficiencies (13)
Failed to ensure transfer documentation was complete for 1 of 2 residents reviewed (Resident 8).
Failed to ensure protection from physical abuse after an abuse allegation for 1 of 5 reviewed (Resident 5).
Failed to ensure an allegation of abuse was reported in a timely manner for 1 of 3 residents reviewed (Resident 5).
Failed to ensure a First Aid and CPR certified staff member was on duty at all times for 5 of 7 days reviewed.
Failed to ensure semi-annual evaluations were completed for 2 of 5 residents reviewed (Resident 5 and Resident 4).
Failed to ensure a current, signed service plan was completed for 5 of 5 residents reviewed (Resident 3, Resident 5, Resident 2, Resident 4, and Resident 6).
Failed to ensure documentation of medications were ordered by a physician for 1 of 5 residents reviewed (Resident 4).
Failed to ensure kitchen sanitation was maintained including unlabeled and undated food items and improper placement of trash can near ice machine.
Failed to ensure pharmacy reviews were completed every 60 days for 4 of 5 residents reviewed (Resident 3, Resident 5, Resident 2, and Resident 6).
Failed to ensure current annual health statements were completed and current for 4 of 5 residents reviewed (Resident 3, Resident 5, Resident 2, and Resident 6).
Failed to ensure documentation of a physical assessment was completed after an abuse allegation for 1 of 3 residents reviewed (Resident 5).
Failed to ensure accurate documentation of the resident's condition preceding death and the disposition of personal belongings for 1 of 2 residents reviewed (Resident B).
Failed to ensure the infection control program analyzed patterns, tracked, trended infections, and ensured antibiotic stewardship.
Report Facts
Census: 66
Dates of survey: April 30, May 1 and 2, 2024
Deficiency counts: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Winchell | Regional Director of Nursing | Signed the report |
| Certified Nurse Aid 4 | Witnessed abuse allegation involving Resident 5 | |
| Qualified Medicine Aide 5 | Reported abuse allegation | |
| Qualified Medicine Aide 6 | Reported abuse allegation and shift change communication | |
| Operations Specialist | Investigated abuse allegation and provided statements | |
| Regional Nurse Specialist | Provided interviews and policies related to transfer documentation, abuse reporting, and infection control |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: Feb 20, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00428598.
Complaint Details
Investigation of Complaint IN00428598 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations are cited. Cedarhurst of Fort Wayne was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00428598.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00423811 and IN00426368.
Complaint Details
Investigation of Complaints IN00423811 and IN00426368 found no deficiencies related to the allegations; facility was compliant.
Findings
No deficiencies related to the allegations in Complaints IN00423811 and IN00426368 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 66
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00418044 and IN00419845.
Complaint Details
Complaint IN00418044 and IN00419845 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations were cited for both complaints. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412028.
Complaint Details
Complaint IN00412028 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 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Renewal
Census: 57
Deficiencies: 3
Date: Mar 23, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on March 21, 22, and 23, 2023, to assess compliance with state residential licensure requirements.
Findings
The facility was found deficient in ensuring first aid certified staff were present for all shifts, maintaining complete personnel orientation records for employees, and performing required fire drills each shift every quarter. Plans of correction were provided with completion dates set for June 1, 2023.
Deficiencies (3)
Failed to ensure first aid certified staff were on premises for 14 of 21 shifts reviewed.
Failed to provide general and specific orientation to 2 of 5 employees reviewed, affecting all 57 residents.
Failed to ensure fire drills were performed each shift every quarter of the last 12 months reviewed.
Report Facts
Residential Census: 57
Shifts lacking first aid certified staff: 14
Employees lacking orientation: 2
Fire drills documented: 8
Fire drills required: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brooke Peters | Executive Director | Named as Executive Director responsible for compliance and signer of the report |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Oct 28, 2022
Visit Reason
This visit was for the investigation of Complaint IN00391851.
Complaint Details
Complaint IN00391851 - Substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00391851 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Date: Oct 4, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391020, which was substantiated with state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00391020 was substantiated with state deficiencies cited at R0088, R0121, and R0410.
Findings
The facility failed to ensure it had a licensed healthcare administrator, failed to ensure 2 of 6 employees received a 2-step tuberculin (TB) screening skin test, and failed to ensure 3 of 12 residents received a 2-step TB screening skin test. The facility followed state guidance but lacked specific policies for these requirements.
Deficiencies (3)
Facility failed to ensure the facility had a licensed healthcare Administrator.
Facility failed to ensure 2 of 6 employees received a 2-step tuberculin (TB) screening skin test.
Facility failed to ensure 3 of 12 residents received a 2-step tuberculin (TB) screening skin test.
Report Facts
Residents present: 54
Employees not fully screened: 2
Residents not fully screened: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Clindaniel | Licensed Administrator | Named as the licensed administrator providing oversight starting October 10, 2022 |
| Ryan Carney | Executive Director | Signed the report |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00385862.
Complaint Details
Complaint IN00385862 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with the relevant regulations.
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