Grey Stone Health & Rehab: Lab Results Never Reported - IN
The resident, identified in inspection records only as Resident L, had been dealing with an acute illness for about a month when nurses noticed he was continuing to weaken and develop respiratory symptoms on September 24, 2025. Labs were drawn during the day. That evening, after he passed black tarry stool, a nurse ordered STAT labs at 11:35 p.m.
Black tarry stool is a sign of gastrointestinal bleeding.
The contracted lab drew the blood at 2:32 a.m. on September 25. Then, instead of taking it to the hospital to be processed as required for STAT orders, the lab ran the tests themselves and reported results back to the facility. The facility never received them.
The contracted nurse practitioner who had been monitoring Resident L reviewed the routine daytime labs from September 24, which came back through the hospital's electronic records system. She had no idea STAT labs had been reordered that same night. Nobody told her. She didn't know the resident had passed black tarry stool. She didn't know his hemoglobin had dropped to 7.7 grams per deciliter.
His hemoglobin had been chronically low, trending between 8 and 10, well below the normal range of 14 to 18 for an adult male. At 7.7, it had fallen further.
On September 30, labs were drawn again, this time based on an order the nurse practitioner had placed the day before. LPN 8, interviewed by inspectors on October 23, said she had drawn those labs but hadn't known why they were ordered. At 6:14 p.m. that evening, the on-call nurse practitioner was notified that Resident L's hemoglobin had hit 5.8, a critical value. She ordered 911 called immediately.
That night, a communication note recorded that Resident L had been admitted to the hospital with a gastrointestinal bleed, anemia, and acute kidney failure.
There were no nursing assessments documenting a change in his condition on either September 29 or September 30.
When inspectors interviewed the Director of Nursing on October 23, she said she wasn't sure why labs had been drawn on September 30 and couldn't find the original order. She also couldn't locate the STAT lab results from September 24. She acknowledged that the contracted lab had processed those samples at their own facility rather than the hospital, and that the results had never made it to Grey Stone.
The nurse practitioner, interviewed separately that same afternoon, said she had been carefully watching Resident L's white blood cell count for signs of infection throughout his illness. She had reviewed the daytime labs on September 24. She had not been told about the STAT reorder that night, had not seen those results, and did not know his hemoglobin had continued to fall. "She should have been notified of the lab results," she told inspectors.
The Director of Nursing told inspectors that following up on lab results and ensuring the ordering provider was informed was the nurses' responsibility. She also said the facility had no specific policy for notifying providers of abnormal lab results.
The Administrator produced a competency form during the inspection that said exactly the opposite: nurses were to call providers, report abnormal results, and document the notification, with critical values requiring immediate contact.
The gap between what the form said and what happened to Resident L was six days.
Inspectors cited the deficiency at the "actual harm" level, meaning the failure caused real injury to a real person, not a theoretical risk. Resident L left Grey Stone in an ambulance with three simultaneous diagnoses, at least one of which, the gastrointestinal bleed, had been signaled nearly a week before anyone with authority to act on it was told.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grey Stone Health & Rehabilitation Center from 2025-10-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 6, 2026 · Our methodology
GREY STONE HEALTH AND REHABILITATION CENTER in FORT WAYNE, IN was cited for violations during a health inspection on October 24, 2025.
Labs were drawn during the day.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.