Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grey Stone Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and on anticoagulant therapy experienced a decline in condition over several weeks, but was not assessed or monitored daily as required. STAT labs were ordered after the resident showed signs of bleeding, but there was no documentation that these labs were completed or that results were communicated to the provider. Critical lab values indicating a significant drop in hemoglobin were not promptly reported, and there were gaps in assessment documentation. The lack of timely follow-up and provider notification led to the resident's hospitalization for gastrointestinal bleeding and blood transfusion.
A resident with dementia and recent hip surgery, dependent on staff for care, was left in a recliner overnight without repositioning or incontinence care, resulting in the development and worsening of a pressure ulcer on the heel. Staff failed to implement timely pressure prevention interventions, did not consistently use protective devices, and did not document care refusals, leading to the progression of the wound.
A resident with a recent hip fracture and surgery developed redness, swelling, and pain in the leg, prompting a NP to order a doppler ultrasound to rule out a blood clot. The order was not entered or completed in a timely manner, and staff failed to document ongoing assessments or communicate the lack of progress. The resident's condition worsened, leading to hospitalization for extensive blood clots and subsequent death.
A resident with a history of colostomy, recurrent small bowel obstructions, and CHF experienced several days of vomiting and no colostomy output, but staff did not promptly notify the physician or nurse practitioner of these changes. Despite multiple staff being aware of the symptoms, there was a lack of timely assessment and escalation, and the care plan did not include monitoring for small bowel obstruction. The resident was eventually sent to the hospital in critical condition and passed away from a small bowel obstruction.
A resident with a history of GERD and gout brought home medications to the facility for short-term rehab. After discharge, the resident reported that two bottles of medication were missing. The medications had been placed in blue bags on the nurse's station desk, and the LPN did not see who picked them up. The facility was unable to locate the medications, and the resident filed a police report. The Administrator acknowledged that the incident was not reported according to facility policy, which requires immediate reporting of misappropriation of resident property.
Two residents' home medications were not properly reconciled or securely stored, resulting in missing medications and the erroneous return of another resident's medications. An LPN left multiple bags of medications, including those belonging to different residents, unsecured at the nurse's station, and there was no documentation of when medications were received or returned. Facility policy requiring documentation and secure storage of home medications was not followed.
A resident with vascular dementia was allegedly hit by a visitor, resulting in a black eye, but the incident was not reported or investigated as required. The following day, the resident was found with additional injuries, yet there was no documentation or reporting of the incident. The facility's policy mandates immediate reporting and investigation of such incidents, which was not followed.
The facility failed to investigate allegations of abuse and injury for two residents. A resident with dementia was involved in an altercation with a visitor, resulting in injuries that were not immediately investigated. The facility's policy requires immediate investigation of such incidents, but this was not followed, leading to a deficiency in ensuring resident safety.
A facility failed to monitor and assess a resident for recurrent urinary retention, leading to a serious health condition. The resident, with dementia and anxiety disorder, was dependent on staff for toileting. Despite a care plan, there was no follow-up on urinary retention observed, and the resident experienced anxiety and low oxygen levels. Hospital records later showed sepsis due to E. Coli bacteremia from a urinary tract infection and urinary retention. The facility lacked a policy for monitoring urinary retention, and documentation showed no urine output for multiple shifts.
A resident admitted without skin impairment developed a stage three pressure ulcer due to the facility's failure to implement effective pressure ulcer prevention and care. Despite being identified as at risk, no interventions were initiated, and documentation was inconsistent, leading to the ulcer's deterioration and infection.
A resident with a history of falls and muscle weakness fell multiple times due to the facility's failure to follow therapy recommendations and ensure proper transfer protocols. Despite therapy advising the use of a Hoyer lift, staff used a sit-to-stand lift without locking the bed wheels, resulting in a fall. The care plan lacked specific transfer instructions, and staff were unaware of the necessary protocols.
A resident with bilateral nephrostomy tubes did not receive appropriate incision care due to a lack of physician orders and inconsistent documentation. The resident's daughter raised concerns about the lack of dressing changes, which were supposed to occur every 3 to 7 days. Observations showed the bandages were in poor condition, and the facility's policies for wound care and physician orders were not followed.
A resident with severe cognitive impairment and multiple cancer diagnoses did not consistently receive the prescribed medication Xtandi due to unavailability. The facility's policy required notifying the physician and documenting missed doses, but there was no record of such actions. The DON noted the resident's wife was to supply the medication, which was unavailable as the resident was soon to be discharged.
Failure to Timely Assess and Follow Up on Lab Orders After Resident Change in Condition
Penalty
Summary
The facility failed to adequately assess a resident and follow up on provider lab orders in a timely manner after a change in condition. A resident with a history of atrial fibrillation, COPD, and dementia, who was on anticoagulant therapy, experienced a decline in condition over several weeks. Despite being at risk for bleeding, the resident was not assessed and charted on daily, and his condition was not closely monitored as required by his care plan. Orders for STAT labs were given after the resident exhibited symptoms such as weakness, moist breath sounds, and passage of black tarry stool, but there was no documentation that these labs were completed or that results were communicated to the provider in a timely manner. The resident's hemoglobin levels were critically low, with a significant drop noted in lab results, but there was a lack of documentation and follow-up regarding these abnormal findings. The contracted NP was not notified of the STAT lab results, and there was confusion among staff regarding lab orders and the process for reporting critical values. The facility's contracted lab did not process the STAT labs as required, and the results were not promptly reported to the facility or the provider. Additionally, there were gaps in documentation of the resident's assessments on multiple days when his condition warranted close monitoring. The DON acknowledged that nurses were responsible for documenting assessments and following up on lab results, but there was no specific facility policy for notifying providers of abnormal lab results. The lack of timely assessment, documentation, and provider notification led to a delay in recognizing the resident's deteriorating condition, ultimately resulting in the resident requiring hospitalization for a gastrointestinal bleed and blood transfusion.
Failure to Provide Timely Pressure Ulcer Prevention and Care
Penalty
Summary
A dependent resident with dementia and a recent right hip fracture, who required significant assistance with activities of daily living and was at risk for skin breakdown, was not provided timely and adequate care to prevent the development and worsening of a pressure ulcer. The resident was left in a recliner chair overnight, in the same clothes and position, without being repositioned or provided with incontinence care, despite being frequently incontinent of bladder and always incontinent of bowel. Staff documented that care was provided, but interviews revealed that no care or pressure prevention interventions were actually performed during the night shift, and the resident's refusal of care was not documented in the nurse notes for the relevant dates. The resident's family discovered the resident in soiled clothing and linens, with a sore on the left heel and dried blood on the sheets that had not been changed for three days. Upon assessment, a deep tissue injury (DTI) was identified on the resident's left heel, which progressed to an unstageable pressure ulcer with eschar and drainage. Observations showed that the heel protector was not consistently in place, and the ordered air mattress was not present on the resident's bed during multiple checks. The care plan and Braden Scale assessments indicated the resident was at risk for pressure ulcers, but appropriate interventions to prevent further skin breakdown were not implemented in a timely manner after the injury was identified. Facility policies required assessment and preventative interventions for residents at risk of pressure injuries, including offloading heels, repositioning, and use of pressure redistribution devices. However, these measures were not consistently followed for this resident, as evidenced by the lack of timely intervention, inconsistent use of protective devices, and failure to document or address care refusals. The delay in implementing physician-ordered treatments and pressure-relieving equipment contributed to the worsening of the resident's pressure ulcer.
Failure to Assess Change in Condition and Follow Provider Orders After Surgery
Penalty
Summary
A deficiency occurred when the facility failed to adequately assess a resident and follow provider orders after a change in condition following hip surgery. The resident, who had a history of left femur fracture, type 2 diabetes mellitus, and dementia, returned to the facility after surgical intervention for a hip fracture. On a specific date, the resident's leg was observed to be red, swollen, and warm, prompting a nurse practitioner to order a doppler ultrasound to rule out a blood clot. However, there was no evidence that this order was entered into the resident's medical record or the treatment administration record, nor was it referenced in progress or therapy notes in the days following the order. Despite the resident continuing to exhibit symptoms such as swelling, redness, and pain in the left leg over several days, there was no documentation of ongoing assessment, vital signs, or pedal pulse checks in the progress notes. The doppler ultrasound order was not processed in a timely manner, with delays in both entering the order into the resident's chart and submitting the request to the mobile ultrasound company. Staff interviews revealed confusion about the process for submitting urgent orders and uncertainty about the availability of the mobile ultrasound service on weekends. Communication lapses occurred, as nurses did not update the nurse practitioner about the resident's status or the lack of completion of the doppler study. The resident's condition deteriorated, and several days after the initial change in condition, the leg was found to be cold, deeply discolored, and pulseless. The resident was then sent to the hospital, where extensive blood clots were confirmed, and the resident was determined not to be a surgical candidate. The resident was admitted to inpatient hospice and subsequently passed away. The facility's failure to assess the resident's change in condition, document findings, and ensure timely completion of the ordered doppler study constituted the deficiency.
Failure to Assess and Report Change in Condition for Resident with Colostomy
Penalty
Summary
A deficiency occurred when the facility failed to assess and report a resident's change in condition to the physician, despite clear signs of clinical deterioration. The resident, who had a history of colostomy, recurrent small bowel obstructions, and congestive heart failure, began experiencing nausea, vomiting, and a lack of colostomy output over several days. Documentation showed that the resident had no stool in her colostomy bag for multiple days and was experiencing ongoing vomiting and weakness, but there was no timely notification to the physician or nurse practitioner regarding these symptoms. Staff interviews revealed that multiple qualified medication aides and LPNs were aware of the resident's symptoms, including vomiting and absence of colostomy output, but did not escalate the situation appropriately. One LPN, who was new to the facility, was unaware of the resident's history of small bowel obstructions and did not contact the on-call NP, instead leaving a note for the NP to review on the next business day. The care plan for the resident did not include specific monitoring for signs and symptoms of small bowel obstruction, such as nausea, vomiting, abdominal pain, or lack of colostomy output, despite the resident's medical history. The facility's policy required immediate notification of the physician and family in the event of a significant change in condition, but this was not followed. The resident's condition continued to deteriorate until she was eventually transported to the hospital, where she was diagnosed with a small bowel obstruction and subsequently passed away. The lack of timely assessment, documentation, and communication with the physician contributed to the deficiency cited in the report.
Failure to Report Missing Resident Medications as Required
Penalty
Summary
The facility failed to ensure that an allegation of missing medication was reported as required for one resident. The resident, who had diagnoses including a fractured femur, GERD, and gout, was admitted for short-term rehabilitation and brought his own supply of Nexium and Mitagare. During his stay, the resident's home medications were administered by staff, and upon discharge, the medications were placed in facility blue bags and left on the nurse's station desk for the resident to collect. The LPN responsible for discharge did not witness who picked up the bags, and the medications were subsequently reported missing by the resident after he returned home. The resident notified the facility about the missing medications, but the facility was unable to locate them. The resident then contacted the sheriff's department and filed a police report. The Administrator and DON became aware of the missing medications and the police involvement, but the Administrator acknowledged that the incident was not reported as required by facility policy. The facility's policy mandates immediate reporting of misappropriation of resident property, including contacting the police and following state-specific procedures, which was not followed in this case.
Failure to Reconcile and Securely Store Home Medications
Penalty
Summary
The facility failed to properly reconcile and securely store medications brought from home for two residents. One resident, admitted for short-term rehabilitation following a hip fracture, reported that staff would not provide his required medications unless he brought them from home. After arranging for his home medications to be delivered to the facility, the resident provided staff with Nexium and Mitagare, which were then administered to him. However, there was no documentation in the medical record regarding when these medications were brought in or the quantity supplied. Upon discharge, the resident was given two facility bags containing medications, but later discovered that two of his medications were missing and that he had been given a bag containing another resident's medications. The staff member responsible for the discharge indicated that the resident's medications had been stored in a secured medication cart and then placed in a blue bag for discharge. The nurse did not know when the medications were brought in or how much was present. The bags containing medications were left on the nurse's station desk, along with a third bag containing another resident's medications, which was to be picked up by a family member. The nurse was not present when the resident left and did not witness who took the bags. The resident later reported the missing medications to the sheriff's department. For the second resident, there was no documentation in the medical record or progress notes indicating that home medications had been brought in, administered, or returned upon discharge. The facility's policies required that medications brought from home be documented, securely stored, and returned to the resident or their family, but these procedures were not followed. Interviews with the administrator and assistant directors of nursing confirmed that medications should not have been left unsecured and that there was no documentation of the medications being returned or reconciled.
Failure to Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse and injury of unknown origin for a resident with vascular dementia and other mental health conditions. An anonymous complaint was made to the Indiana Department of Health, alleging that the resident had been hit by a visitor and was found with a black eye the following day. On a specific date, a nurse progress note indicated that the resident had wandered into another resident's room and was hitting their visitor, who then grabbed the resident's shoulder to remove her from the room. Witness statements confirmed the incident, but there was no further documentation or reporting of the incident as required by the facility's policy. The following day, the resident was observed with a laceration above her right eye and a skin tear on her right hand, but she was unable to explain how the injuries occurred. A focused observation noted the resident's anxiety and additional injuries, yet there was no documentation indicating the incident had been reported or investigated. The facility's policy requires immediate reporting and investigation of such incidents, but the administrator confirmed that these incidents were not reported to her or the state agency as required.
Failure to Investigate Allegations of Abuse and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse and injury of unknown source for two residents, Resident F and Resident G. An anonymous complaint was reported to the Indiana Department of Health, alleging that Resident F had been hit by a visitor and was found with a black eye the following day. Resident F, who resided in a secured memory care unit, had diagnoses including vascular dementia with agitation, delusional disorder, and major depressive disorder. She was noted to have severely impaired cognition and exhibited wandering behaviors. On 10/20/24, Resident F wandered into another resident's room and hit a visitor, who then grabbed her shoulders to remove her from the room. Witness statements were obtained, but there was no further documentation of an investigation into the incident or protection measures for Resident F. The report indicates that there was no documentation from 10/20/24 at 5:00 p.m. until 10/21/24 at 7:00 a.m. when a nurse noted Resident F had a laceration above her right eye and a skin tear on her right hand. The injuries were treated, but Resident F was unable to explain how they occurred. A focused head-to-toe observation noted bruising and a skin tear, but the psychiatric NP's progress note did not connect these injuries to the altercation with the visitor. The interdisciplinary note also failed to mention the altercation or investigate the injury's origin. Interviews with staff revealed that the altercation had not been reported to the ADON, and the facility's wound nurse was unaware of the incident. The facility's policy requires immediate investigation of all allegations of abuse and injuries of unknown source, but this was not followed. The Administrator acknowledged that both incidents should have been investigated immediately. The lack of documentation and investigation into the altercation and subsequent injuries to Resident F represents a failure to comply with the facility's abuse policy and to ensure resident safety.
Failure to Monitor and Assess Urinary Retention
Penalty
Summary
The facility failed to adequately monitor and assess a resident, identified as Resident E, for recurrent urinary retention, which contributed to a serious health condition. Resident E, who had diagnoses including dementia, COPD, and anxiety disorder, was noted to have severely impaired cognition and was dependent on staff for toileting. Despite a care plan in place to manage incontinence and prevent complications, there was a lack of documentation and follow-up regarding urinary retention observed on 8/6/24. The resident was found to have a distended abdomen and was straight cathed, removing 1000 milliliters of urine, yet there was no subsequent monitoring or assessment for urinary retention or its recurrence. The resident experienced intermittent episodes of anxiety, fast heart rate, and low oxygen levels, but the facility did not investigate the cause of urinary retention. Hospital records later indicated that Resident E was diagnosed with sepsis due to E. Coli bacteremia from a urinary tract infection and urinary retention. The facility lacked a policy for assessing and monitoring urinary retention, and documentation showed no urine output for 1 to 2 shifts on multiple days. The resident's daughter reported chronic issues with toileting and personal hygiene, which she believed contributed to the infection and subsequent death of her father.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide effective pressure ulcer care and prevention for Resident 243, who was admitted without skin impairment. Despite initial assessments indicating intact skin, subsequent records showed inconsistencies and omissions in monitoring and documenting skin conditions. A Braden Scale assessment identified Resident 243 as at risk for pressure ulcers, yet no interventions were implemented to prevent skin breakdown. Weekly skin assessments were incomplete, and skilled nursing notes lacked detailed wound assessments, leading to a deterioration of a facility-acquired skin impairment into a stage three pressure injury with infection. Resident 243's medical history included a traumatic brain injury, diabetes with polyneuropathy, and paresthesia, which increased his vulnerability to skin breakdown. Despite these risk factors, the facility did not develop a comprehensive care plan to address pressure relief for the resident's left elbow, where the pressure ulcer developed. The care plan was only initiated after the ulcer had progressed, and it included interventions such as using an air mattress and pressure-reducing cushions, which were not documented as being implemented in a timely manner. The facility's documentation and communication failures contributed to the inadequate care. There were gaps in nursing notes, missing wound assessments, and a lack of communication between CNAs and nursing staff regarding skin concerns. The facility's policies on skin and wound care were not followed, as evidenced by the lack of systematic skin inspections and the failure to implement evidence-based interventions promptly. These deficiencies resulted in the resident's pressure ulcer worsening and requiring antibiotic treatment for cellulitis.
Failure to Follow Transfer Protocols Leads to Resident Falls
Penalty
Summary
The facility failed to ensure proper interventions were followed to prevent falls for a resident, identified as Resident 22, who experienced multiple falls since admission. Resident 22, who had diagnoses including drug-induced polyneuropathy, repeated falls, unsteadiness on feet, and muscle weakness, reported falling three times within a month of admission. During a transfer using a sit-to-stand lift, the resident's knees gave out, and the bed moved away because the wheels were not locked, resulting in the resident being lowered to the floor. The care plan for Resident 22 indicated the bed should be kept in the lowest position with brakes locked, but it did not specify the use of a lift or the number of staff required for transfers. Interviews and record reviews revealed that therapy staff had recommended using a Hoyer lift for transfers, and this recommendation was not followed by the nursing staff. A therapy note indicated that the resident had limited standing tolerance, and a physician's order allowed the use of a Hoyer lift when fatigue was present. However, the CNA involved in the transfer was unaware of the care plan details and the Kardex, which should have directed staff care. The DON confirmed that therapy recommendations should be followed and that the bed should have been locked prior to the transfer. The facility's Mechanical Lift Policy required transfer status to be determined upon admission and as needed, based on nursing judgment or therapy recommendation, which was not adhered to in this case.
Failure to Provide Nephrostomy Care
Penalty
Summary
The facility failed to provide appropriate nephrostomy incision care for Resident Z, who was admitted with bilateral nephrostomy tubes due to multiple health conditions, including prostate cancer, bladder cancer, and end-stage kidney disease. Upon review, it was found that Resident Z's nephrostomy dressing had not been changed since admission, and there were no physician orders for nephrostomy tube site care. The resident's care plan did not include instructions for dressing changes, and the Director of Nursing (DON) was unaware of the nephrostomy care needs due to being new to the facility. Observations and interviews revealed inconsistencies in the documentation and care provided to Resident Z. Skilled Nursing Notes indicated conflicting information about the presence of a urinary catheter and surgical incisions. The resident's daughter expressed concerns about the nephrostomy tube being displaced and the lack of dressing changes, which were supposed to occur every 3 to 7 days as per hospital instructions. The facility's policy required wounds to be assessed and dressings applied as ordered by a physician, but this was not followed. The facility's failure to ensure proper nephrostomy care was further highlighted by the condition of the bandages observed during inspections. The right nephrostomy tube bandage was missing a portion of its covering, and the left bandage was creased and illegible. The facility's policies required reviewing all referring facility information to determine appropriate admission orders and contacting the physician for additional orders based on medical treatment needs, which was not adequately executed in this case.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to ensure that a prescribed medication, Xtandi, was consistently provided to a resident diagnosed with bone cancer, prostate cancer, and bladder cancer. On a specific date, an LPN was observed unable to locate the medication in the medication cart or the facility's medication dispensary machine. The resident's Medication Administration Record (MAR) indicated that Xtandi was not administered on several occasions due to the medication being on order or unavailable, and there was no documentation of notification to the pharmacy or the prescribing physician about the unavailability of the medication. The Director of Nursing (DON) indicated that the resident's wife was responsible for supplying the medication to the facility and that the medication was unavailable on the day of the observation because the resident was to be discharged soon. The facility's policy required notifying the resident's physician if a medication was unavailable and documenting the circumstances of any missed doses in the MAR and progress notes. However, the progress notes did not reflect any notification to the pharmacy or physician regarding the unavailability of Xtandi.
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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) |
|---|---|---|---|---|
| Ashton Creek Health And Rehabilitation Center | 0.7 mi | — | 0 | 0 |
| Heritage Pointe Of Fort Wayne | 1.7 mi | — | 4 | 0 |
| Lutheran Life Villages | 2.4 mi | — | 2 | 0 |
| Bethlehem Woods Nursing And Rehabilitation | 2.9 mi | — | 6 | 0 |
| Towne House Retirement Community | 3.5 mi | — | 0 | 0 |
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