Byron Health Center: Suicide Report Ignored for Weeks - IN
The resident, identified in inspection records as Resident 77, had been diagnosed with Alzheimer's disease, anxiety, and depression. A cognitive assessment from January 2026 scored her a 4 on a standard mental status scale, placing her in the severely impaired range. Her care plan, which addressed her depression and history of suicidal ideation, instructed staff to redirect her when she made comments about wanting to harm herself and to notify a supervisor immediately when such comments occurred.
The volunteer who heard the statement, identified as Volunteer 4, said Resident 77 told him during a brief visit on the afternoon of March 9 that she had nothing to live for and wanted to kill herself. The visit lasted three minutes. Volunteer 4 said he responded with kind words and tried to find the nurse on her unit. He could not locate anyone, so he walked to an adjacent unit and reported what she had said to staff there.
What happened after that is where the system broke down entirely.
Volunteer 4 also recorded the statement in a handwritten visit log, the kind used to document one-on-one resident visits. Those logs were collected by the Life Enrichment Specialist, identified as LCS 2, who entered them into the facility's computer system on a weekly basis. LCS 2 told inspectors she read Resident 77's entry on March 18, nine days after the visit. She said she recognized immediately that she should have reported the suicidal statement to the Resident Engagement Specialist as soon as she became aware of it.
She did not report it.
The progress note documenting the March 9 statement was entered at 4:24 PM that day. Inspectors reviewing Resident 77's records on March 25 found no additional progress notes about suicidal ideation. No Columbia Suicide Severity Rating Scale had been completed. No provider had been notified. No orders had been issued or followed.
The Director of Nursing told inspectors on March 27 that any resident verbalizing suicidal ideation should be asked directly whether they had a plan to harm themselves. The DON said the resident's care plan should be reviewed and followed in those situations, and that a nurse practitioner could authorize inpatient psychiatric care if it was deemed appropriate. None of that had happened.
A Qualified Medicine Aide who worked regularly on Resident 77's unit said she had no idea the statement had been made. QMA 3 told inspectors she knew from Resident 77's admission several months earlier that the woman had made suicidal remarks when she was confused, but she said she was completely unaware of what Resident 77 had told the volunteer on March 9.
The administrator, interviewed on the afternoon of March 27, said she had just learned about the verbalization and was still trying to determine where the communication failure had occurred. She described what should have happened: staff notify the nursing supervisor, a suicide risk assessment is completed, results go to the provider, and any orders are carried out and documented. A copy of the facility's suicide threat policy, dated February 2018 and provided to inspectors that afternoon, described the same sequence in writing.
None of it was done.
The gap between what the policy required and what actually occurred was not a matter of interpretation. A volunteer followed the statement all the way to adjacent-unit staff. A life enrichment specialist read it in a log and recognized it as something she should have escalated. A care plan already in place named this exact situation and told staff exactly what to do. The machinery for responding existed. It simply did not move.
What makes the failure harder to explain is that Resident 77 was not an unknown quantity. Her history of suicidal ideation was documented. Staff who worked her unit knew she had made similar remarks at admission. Her condition, severe cognitive impairment layered over depression and anxiety, is precisely the profile that suicide risk protocols are designed to protect. The care plan named her by that profile. It just did not protect her.
Federal inspectors cited the deficiency under standards governing the care of residents with mental health conditions and trauma histories. The citation noted minimal harm or potential for actual harm and listed the number of residents affected as few.
Resident 77 was 77 days into a care plan that acknowledged she might say she wanted to die, and instructed staff to act immediately when she did. On March 9, she said it. A volunteer heard her, tried to find help, wrote it down. A staff member read it nine days later and recognized it as a problem.
Nobody called the supervisor. Nobody sat with her and asked if she had a plan. Nobody picked up the phone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Byron Health Center from 2026-03-31 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: June 17, 2026 · Our methodology
BYRON HEALTH CENTER in FORT WAYNE, IN was cited for violations during a health inspection on March 31, 2026.
The resident, identified in inspection records as Resident 77, had been diagnosed with Alzheimer's disease, anxiety, and depression.
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.
Frequently Asked Questions
- What happened at BYRON HEALTH CENTER?
- The resident, identified in inspection records as Resident 77, had been diagnosed with Alzheimer's disease, anxiety, and depression.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in FORT WAYNE, IN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from BYRON HEALTH CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 155364.
- Has this facility had violations before?
- To check BYRON HEALTH CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.