Inspection Reports for Golden Years Homestead
3136 Goeglein Rd, Fort Wayne, IN 46815, IN, 46815
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Inspection Report
Plan of Correction
Deficiencies: 0
Jun 16, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00457494 and IN00457512 completed on May 5, 2025.
Findings
Golden Years Homestead was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the investigations of Complaints IN00457494 and IN00457512.
Complaint Details
Complaints IN00457494 and IN00457512 were reviewed and found to be corrected.
Report Facts
Complaint Investigation IDs: Complaints IN00457494 and IN00457512
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 3
May 7, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00457494, IN00457512, and IN00458000, focusing on allegations related to medication administration and resident behavior.
Findings
The facility failed to ensure proper medication administration for one resident and failed to identify, intervene, and document inappropriate touching behaviors for two residents. Additionally, the facility did not maintain complete and accurate medical records related to these incidents.
Complaint Details
Complaint IN00457494 and IN00457512 involved allegations of medication errors and inappropriate touching behaviors. Complaint IN00458000 had no deficiencies cited.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a resident was administered medication as ordered by the physician (Resident Q). | SS=D |
| Failed to ensure a resident's inappropriate touching behavior was identified, prevention interventions implemented, and behavior trended (Residents D and E). | SS=D |
| Failed to maintain complete and accurate medical records for residents related to inappropriate touching incidents (Residents D and E). | SS=D |
Report Facts
Census: 84
Licensed beds: 84
Medication doses missed: 4
Medication doses administered without order: 6
Behavior monitoring audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Schaaf | HFA, V.P. Operations | Signed report as provider/supplier representative |
| RN 9 | Registered Nurse | Interviewed regarding medication administration error |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication error and behavior incidents; provided facility policies |
| CNA 4 | Certified Nurse Aid | Reported inappropriate touching incident on 4/7/25 |
| QMA 2 | Qualified Medication Aid | Reported observation of inappropriate touching incident |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding behavior management and documentation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
Apr 15, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456617.
Findings
No deficiencies related to the allegations in Complaint IN00456617 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00456617 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 9
Medicaid residents: 60
Other residents: 18
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Feb 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452300.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00452300 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 85
Census Bed Type - SNF/NF: 83
Census Bed Type - SNF: 2
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 130
Deficiencies: 0
Dec 17, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00448116 and IN00449270 at Golden Years Homestead.
Findings
No deficiencies related to the allegations in complaints IN00448116 and IN00449270 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Investigation of Complaints IN00448116 and IN00449270 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census Bed Type - SNF/NF: 84
Census Bed Type - Residential: 46
Census Total: 130
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 70
Inspection Report
Follow-Up
Census: 90
Capacity: 111
Deficiencies: 0
Dec 3, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 10/10/24.
Findings
At the Emergency Preparedness PSR, the facility was found in compliance with Emergency Preparedness Requirements. At the Life Safety Code PSR, the facility was found in compliance with Life Safety Code requirements including fire safety and sprinkler systems.
Report Facts
Certified beds: 111
Census: 90
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Nov 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446818.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00446818 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 91
Census Payor Type Total: 94
SNF Beds: 5
SNF/NF Beds: 86
Medicare Residents: 10
Medicaid Residents: 58
Other Payor Residents: 23
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Oct 16, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00444043 and IN00444713 at Golden Years Homestead.
Findings
No deficiencies related to the allegations in complaints IN00444043 and IN00444713 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00444043 and IN00444713 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census Bed Type: 94
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 26
Inspection Report
Life Safety
Census: 99
Capacity: 111
Deficiencies: 7
Oct 10, 2024
Visit Reason
The survey was conducted as an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including failure to have emergency preparedness policies for LTC roles under a waiver, failure to conduct required emergency plan exercises, deficiencies in kitchen hood extinguishing system appliance placement, fire alarm system time accuracy, sprinkler system inspection documentation and maintenance, fire door annual inspection, and improper use of multiplug power strips in resident rooms and offices.
Severity Breakdown
SS=F: 4
SS=E: 2
SS=C: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness policies include the role of the LTC facility under a waiver declared by the Secretary. | SS=F |
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Failed to provide an approved method for returning cooking appliances to their approved design location under kitchen hood extinguishing systems. | SS=E |
| Fire alarm system control panel time was incorrect and not continuously in proper operating condition. | SS=C |
| Failed to document sprinkler system inspections in accordance with NFPA 25 and failed to clean sprinkler heads covered with lint. | SS=F |
| Failed to ensure annual inspection and testing of oxygen storage room fire door assembly. | SS=F |
| Failed to ensure multiplug power strip in resident room met UL 1363 and improper use of power strips for refrigerators in offices. | SS=E |
Report Facts
Facility capacity: 111
Census: 99
Number of sprinkler systems: 4
Number of resident rooms inspected for power strip: 52
Number of refrigerators plugged into power strips: 3
Inspection Report
Annual Inspection
Census: 42
Capacity: 140
Deficiencies: 4
Sep 23, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including an investigation of complaints IN00440828, IN00442467, and IN00443361.
Findings
The facility was found to have deficiencies including substantiated physical abuse of a resident by a staff member, failure to implement trauma-informed care interventions for a resident, failure to date and discard expired medications on medication carts, and failure to maintain infection control measures for oxygen tubing. Some complaints were unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00440828 was unsubstantiated due to lack of evidence. Complaint IN00442467 was unsubstantiated due to lack of evidence. Complaint IN00443361 was substantiated with citation F600 related to physical abuse.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 5 residents reviewed were free of abuse; substantiated physical abuse by QMA 6 to Resident 26. | SS=D |
| Facility failed to ensure interventions were implemented to prevent feelings of fear for 1 of 2 residents reviewed (Resident 3). | SS=D |
| Facility failed to ensure medications were dated when opened and destroyed when expired in 2 of 4 medication carts. | SS=E |
| Facility failed to ensure infection control measures were maintained for oxygen tank tubing for 2 of 3 residents reviewed (Residents 16 and 247). | SS=D |
Report Facts
Survey dates: 5
Residents reviewed for abuse: 5
Residents reviewed for trauma care: 2
Medication carts reviewed: 4
Oxygen tubing residents reviewed: 3
Facility total capacity: 140
Current census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Schaaf | HFA, V.P. Operations | Signed the report as provider/supplier representative. |
| QMA 6 | Qualified Medication Assistant | Named in substantiated physical abuse finding involving Resident 26; subsequently released from employment. |
| Director of Nursing | Director of Nursing (DON) | Provided statements and investigation details related to abuse incident and trauma-informed care policy. |
| Maintenance Supervisor | Maintenance Supervisor | Provided information about camera recordings related to abuse incident. |
| Restorative Aid | Restorative Aid | Provided information about abuse training and facility policy. |
| Human Resources | Human Resources (HR) | Reported missing video footage related to abuse incident. |
| Memory Care Manager | Memory Care Manager (MCM) | Involved in investigation and recovery of QMA badge from Resident 26. |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 23, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, along with an investigation of Complaint IN00443361.
Findings
Golden Years Homestead was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the recertification, state licensure survey, and complaint investigation. The complaint IN00443361 was corrected.
Complaint Details
Complaint IN00443361 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 130
Deficiencies: 0
Jul 30, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00439351 and IN00439507.
Findings
No deficiencies related to the allegations in complaints IN00439351 and IN00439507 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00439351 and IN00439507 found no deficiencies related to the allegations; facility was compliant.
Report Facts
Census Bed Type - SNF/NF: 90
Census Bed Type - Residential: 40
Total Census: 130
Census Payor Type - Medicaid: 83
Census Payor Type - Other: 47
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Jul 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437865.
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.
Complaint Details
Complaint IN00437865 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Jun 10, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00433859 and IN00434553, including the investigation of Residential Complaint IN00433441.
Findings
No deficiencies related to the allegations were cited for complaints IN00433859 and IN00434553. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigations.
Complaint Details
Complaint IN00433859 and Complaint IN00434553 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 97
SNF/NF beds: 93
SNF beds: 4
Medicare residents: 21
Medicaid residents: 54
Other residents: 22
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 25, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN004031247 completed on April 4, 2024.
Findings
Golden Years Homestead was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN004031247 completed with findings of compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 10, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00429037 completed on March 12, 2024.
Findings
Golden Years Homestead was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00429037 completed on March 12, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 1
Apr 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431247 regarding allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Findings
The facility failed to ensure that an injury of unknown origin for one resident (Resident D) was reported timely to the appropriate authorities. Documentation and investigation into the injury were insufficient, and staff did not report the injury as required by policy.
Complaint Details
Complaint IN00431247 was substantiated with federal/state deficiencies cited at F609 related to failure to report injuries of unknown origin and failure to investigate and follow up on the injury for Resident D.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an injury of unknown origin for Resident D in a timely manner as required by federal and state regulations. | SS=D |
Report Facts
Census: 93
Total Capacity: 93
Medicare Residents: 6
Medicaid Residents: 60
Other Payor Residents: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Schaaf | HFA, V.P. Operations | Signed the report |
| Director of Nursing | Interviewed regarding failure to report injuries; name not fully provided |
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 1
Mar 11, 2024
Visit Reason
This visit was conducted to investigate multiple complaints including IN00428352, IN00428429, IN00429037, IN00428929, and IN00429177 related to the facility.
Findings
The investigation found no deficiencies related to complaints IN00428352, IN00428429, IN00428929, and IN00429177. However, federal and state deficiencies were cited related to complaint IN00429037 concerning failure to timely notify the physician and family of a significant change in condition for one resident (Resident D).
Complaint Details
Complaint IN00428352 - No deficiencies related to the allegations are cited. Complaint IN00428429 - No deficiencies related to the allegations are cited. Complaint IN00429037 - Federal/State deficiencies related to the allegations are cited at F580. Complaint IN00428929 - No deficiencies related to the allegations are cited. Complaint IN00429177 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the physician and family timely of a significant change in condition for Resident D, including pain complaints, diarrhea, and isolation status. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 90
Census Bed Type - SNF: 5
Census Bed Type - Residential: 43
Census Bed Type - Total: 138
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 23
Census Payor Type - Total: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Mentioned in relation to lack of awareness of Resident D's pain and failure to find documentation of NP visit | |
| Assistant Director of Nursing | Provided the current policy titled 'Notification of Changes' | |
| Qualified Medication Aide 2 | Interviewed regarding Resident D's complaints and isolation cart placement | |
| LPN 3 | Weekend supervisor on 12/31/23, interviewed about Resident D's isolation and notification |
Inspection Report
Re-Inspection
Census: 91
Deficiencies: 0
Feb 15, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00425478 and IN00426117 completed on January 30, 2024.
Findings
Golden Years Homestead was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaints IN00425478 and IN00426117. Both complaints were corrected.
Complaint Details
This visit was related to complaints IN00425478 and IN00426117. Both complaints were found to be corrected.
Report Facts
Census Bed Type Total: 91
Census Payor Type Total: 91
SNF/NF beds: 87
SNF beds: 4
Medicare residents: 11
Medicaid residents: 54
Other payor residents: 26
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 2
Jan 29, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00425478 and IN00426117, which involved allegations related to resident safety during transportation and quality of care.
Findings
The facility failed to ensure a resident was properly secured in a wheelchair during van transport, resulting in the resident falling and sustaining a spinal injury. The facility lacked a policy and safety assessment for van transport and did not have a comprehensive QAPI program to monitor transportation safety. Corrective actions included training van drivers on proper securing procedures and implementing a detailed policy and ongoing audits.
Complaint Details
The investigation was triggered by complaints IN00425478 and IN00426117. The complaints were substantiated with federal/state deficiencies cited at F689 and F865. The Immediate Jeopardy began on 2024-01-03 when a resident slid out of his wheelchair during transport and sustained a spinal injury. The Immediate Jeopardy was removed on 2024-01-30 after corrective training was completed.
Severity Breakdown
Immediate Jeopardy: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident was effectively secured in the wheelchair during van transport, resulting in a fall and spinal injury. | Immediate Jeopardy |
| Failed to implement a comprehensive Quality Assurance and Performance Improvement (QAPI) program to ensure safe transportation for residents. | Level E |
Report Facts
Census: 90
Total Capacity: 90
Residents using van transportation: 43
Survey dates: 2024-01-29 to 2024-01-30
Immediate Jeopardy removal date: Jan 30, 2024
Training completion date: Jan 5, 2024
QAPI monitoring period: 1
Regulatory compliance system duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Schaaf | HFA, V.P. Operations | Signed the report as provider/supplier representative |
| Van Driver 3 | Named in the incident involving improper securing of resident in wheelchair during transport | |
| Administrator | Conducted investigation of the incident and provided statements regarding corrective actions | |
| Director of Nursing | Notified of Immediate Jeopardy and involved in corrective action oversight | |
| Maintenance Director | Responsible for training van drivers and managing van safety procedures | |
| Assistant Director of Nursing | Informed about the incident and involved in auditing van safety | |
| Director of Maintenance Services | Provided in-service training on securing wheelchair-bound residents in the van | |
| Environmental Services Supervisor | Involved in auditing van safety and resident security during transport |
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 0
Dec 7, 2023
Visit Reason
This visit was conducted to investigate multiple complaints identified as IN00420314, IN00420799, IN00422296, IN00422545, IN00422613, IN00422654, and IN00423474.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00420314, IN00420799, IN00422296, IN00422545, IN00422613, IN00422654, and IN00423474 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 4
Census Bed Type - SNF/NF: 90
Census Bed Type - Residential: 42
Total Census: 136
Census Payor Type - Medicare: 24
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 70
Inspection Report
Re-Inspection
Census: 96
Capacity: 111
Deficiencies: 0
Nov 15, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 10/12/23.
Findings
At this PSR survey, Golden Years Homestead was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Life Safety
Census: 96
Capacity: 111
Deficiencies: 4
Oct 12, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including failure to perform annual fuel quality testing of the emergency generator, failure to inspect fire damper systems every four years, and improper segregation and marking of oxygen cylinders in storage.
Severity Breakdown
SS=F: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement emergency power system requirements including annual fuel quality testing of the emergency generator. | SS=F |
| Failed to ensure fire damper systems were inspected and maintained after the first year and at least every four years as required by NFPA 90A. | SS=F |
| Failed to ensure annual fuel quality test was performed for the facility diesel powered generator. | SS=F |
| Failed to ensure empty oxygen cylinders are segregated from full cylinders and marked to avoid confusion. | SS=E |
Report Facts
Facility capacity: 111
Census: 96
Fuel quality test date: Jan 14, 2022
Fire damper last inspection date: Mar 30, 2018
Generator exercise frequency: 12
Generator exercise duration: 30
Generator extended exercise interval: 36
Oxygen storage audit frequency initial: 3
Oxygen storage audit frequency follow-up: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Schaaf | HFA, V.P. Operations | Signed the report as provider/supplier representative |
| Director of Maintenance | Interviewed regarding deficiencies related to emergency power system, fire damper inspection, and oxygen cylinder storage |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Oct 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418552 at Golden Years Homestead.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00418552 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 98
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 30
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 1
Sep 12, 2023
Visit Reason
This visit was conducted for the investigation of two complaints (IN00417181 and IN00415824) in conjunction with a Recertification State Licensure Survey.
Findings
The facility failed to ensure physician orders were followed for 2 of 2 residents reviewed, specifically regarding timely administration and documentation of narcotic medications including Fentanyl patches and Norco. Medication availability issues and discrepancies in medication administration records were noted.
Complaint Details
The investigation was related to complaints IN00417181 and IN00415824. Federal deficiencies related to the allegations were cited at F684. The complaints involved failure to follow physician orders and medication administration issues.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow physician orders for narcotic medication administration for Resident 9 and Resident 198. | SS=D |
Report Facts
Census: 96
Total Capacity: 96
Survey Dates: 5
Medicare Census: 6
Medicaid Census: 61
Other Payor Census: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Schaaf | HFA, V.P. Operations | Signed as provider/supplier representative on the report |
| RN 4 | Nurse who removed and replaced Fentanyl patches on Resident 9 and provided information about medication orders | |
| DON | Director of Nursing | Provided information about medication order issues, pharmacy contract, and documentation problems |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 12, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00417181 completed on September 12, 2023.
Findings
Golden Years Homestead was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00417181; paper compliance review found facility in compliance.
Inspection Report
Recertification
Census: 96
Deficiencies: 7
Sep 12, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigations of Complaints IN00415824 and IN00417181, and a State Residential Licensure Survey.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident self-determination regarding shower and meal choices, failure to follow physician orders for medication administration, inadequate pain management, failure to provide trauma-informed care, and food safety violations related to dishwasher temperature and dumpster sanitation.
Complaint Details
This visit included investigations of Complaint IN00415824 and Complaint IN00417181, both related to federal deficiencies cited at F684.
Severity Breakdown
SS=D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure preferences and options for showers and meals were offered and observed for Resident 40. | SS=D |
| Failed to ensure physician orders were followed for Residents 9 and 198, including medication availability and administration. | SS=D |
| Failed to ensure safety for Resident 9 related to elopement risk assessment and care planning. | SS=D |
| Failed to provide adequate pain management for Resident 13, including lack of non-pharmacological interventions and pain assessments. | SS=D |
| Failed to ensure residents receive culturally competent, trauma-informed care for Resident 49. | SS=D |
| Failed to maintain sanitary kitchen conditions, including dishwasher wash temperature below required levels. | SS=D |
| Failed to ensure garbage and refuse were properly contained inside the dumpster. | SS=D |
Report Facts
Survey dates: 5
Census SNF/NF beds: 91
Census SNF beds: 5
Total census: 96
Medicare census: 6
Medicaid census: 61
Other payor census: 29
Resident 9 BIMS score: 12
Resident 40 BIMS score: 13
Resident 49 BIMS score: 15
Resident 13 BIMS score: 15
Dishwasher wash temperature: 80
Dishwasher rinse temperature: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Schaaf | HFA, V.P. Operations | Signed the report. |
| RN 4 | Registered Nurse | Interviewed regarding Resident 9's medication and elopement. |
| Director of Nursing | Provided information on shower schedule changes, medication issues, and policies. | |
| Dietary Cook 6 | Interviewed regarding meal options for residents. | |
| Dietary Manager | Interviewed regarding dishwasher and dumpster conditions. | |
| Maintenance Director | Interviewed regarding dumpster maintenance. |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 12, 2023
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey and the Investigation of Complaint IN00415824.
Findings
Golden Years Homestead was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the recertification, state licensure survey, and complaint investigation.
Complaint Details
Investigation of Complaint IN00415824 completed on September 12, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 137
Deficiencies: 0
Aug 21, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00415028 and IN00415509.
Findings
No deficiencies related to the allegations in complaints IN00415028 and IN00415509 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00415028 and IN00415509 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 94
Census Bed Type - SNF: 4
Census Bed Type - Residential: 39
Census Bed Type - Total: 137
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 30
Census Payor Type - Total: 98
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
May 5, 2023
Visit Reason
This visit was for the investigation of Complaint IN00407910.
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.
Complaint Details
Investigation of Complaint IN00407910; no deficiencies related to the allegations were found.
Report Facts
Facility number: 282
Residential Census: 39
Inspection Report
Complaint Investigation
Census: 99
Capacity: 143
Deficiencies: 0
Feb 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399280.
Findings
The complaint IN00399280 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00399280 was investigated and found to be unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF beds: 94
Census SNF beds: 5
Census Residential beds: 44
Total licensed capacity: 143
Census Medicare residents: 11
Census Medicaid residents: 66
Census Other payor residents: 22
Total census residents: 99
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 8, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on October 21, 2022.
Findings
Golden Years Homestead was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 101
Capacity: 111
Deficiencies: 4
Nov 22, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements and Life Safety Code requirements. However, deficiencies were identified related to emergency generator testing and fire watch policies, including failure to document a required 4-hour generator load test and incomplete fire watch procedures for fire alarm and sprinkler system outages.
Severity Breakdown
SS=C: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| The emergency generator lacked the required 4-hour run under load testing as required by Life Safety Code and NFPA 110. | SS=C |
| The facility failed to provide a complete written fire watch policy indicating procedures to follow when the fire alarm system is out of service for more than 4 hours, including proper notification to the Indiana Department of Health. | SS=C |
| The facility failed to provide a correct written policy for fire watch procedures when the sprinkler system is out of service for more than 10 hours, including notification to the Indiana Department of Health. | SS=C |
| The facility failed to maintain the Emergency Power Standby System in accordance with NFPA 110, lacking documentation of a required 4-hour continuous run test within the last 36 months. | SS=C |
Report Facts
Facility capacity: 111
Census: 101
Deficiencies cited: 4
Generator load test interval: 36
Generator weekly inspections: 1
Generator load exercises: 12
Generator 4-hour test interval: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Schaaf | HFA, V.P. Operations | Signed the report as provider/supplier representative |
| Maintenance Director | Interviewed regarding generator testing and fire watch policies |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 0
Oct 21, 2022
Visit Reason
The visit was conducted for the investigation of three complaints (IN00392744, IN00392799, and IN00392903) in conjunction with a Recertification and State Licensure Survey and a State Residential Licensure Survey.
Findings
Complaint IN00392744 and IN00392799 were unsubstantiated due to lack of evidence. Complaint IN00392903 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC.
Complaint Details
Complaint IN00392744 and IN00392799 were unsubstantiated due to lack of evidence. Complaint IN00392903 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 139
SNF beds: 3
SNF/NF beds: 93
Residential beds: 43
Medicare residents: 6
Medicaid residents: 71
Other payor residents: 62
Inspection Report
Recertification
Census: 43
Deficiencies: 6
Oct 21, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey, and was conducted in conjunction with the Investigation of Complaints IN00392744, IN00392799, and IN00392903.
Findings
The facility was found to have multiple deficiencies including failure to complete appropriate PASARR assessments, failure to coordinate hospice care, failure to implement resident-specific fall interventions, failure to monitor adverse medication side effects including psychotropic medications, and medication administration errors exceeding 5%. The facility was found to be in compliance with State Residential Licensure Survey requirements.
Complaint Details
This survey was conducted in conjunction with the Investigation of Complaints IN00392744, IN00392799, and IN00392903.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure assessment for appropriate placement was completed for 1 of 5 residents reviewed (Resident 95). | SS=D |
| Failed to coordinate care with hospice for 1 of 4 residents reviewed (Resident 92). | SS=D |
| Failed to implement resident specific fall interventions for 1 of 4 residents reviewed (Resident 69). | SS=D |
| Failed to ensure adverse medication side effects were monitored for 2 of 3 residents reviewed (Resident 63 and Resident 25). | SS=D |
| Failed to ensure adverse psychotropic medication side effects were monitored for 4 of 4 residents reviewed (Resident 25, Resident 15, Resident 82, and Resident 88). | SS=E |
| Medication administration errors were above 5% with an error rate of 56% for 2 of 4 residents observed (Resident 76 and Resident 53). | SS=D |
Report Facts
Survey dates: 5
Census: 43
Medication administration error rate: 56
Medication administration opportunities: 25
Medication administration errors: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Schaaf | HFA, V.P. Operations | Signed the report as provider/supplier representative. |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Sep 7, 2022
Visit Reason
This visit was for the Investigation of Residential Complaint IN00387833 and included the Investigation of Nursing Home Complaint IN00387526.
Findings
Complaint IN00387833 was substantiated, but no State Residential Findings related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of Complaint IN00387833.
Complaint Details
Complaint IN00387833 - Substantiated. No State Residential Findings related to the allegations were cited.
Report Facts
Residential Census: 38
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