Byron Health Center

prevent accidents.

completed after falls for 3 of 8 residents reviewed. (Resident 6, Resident 13, and Resident

epilepsy, dementia, and diabetes. In an interview, on 03/26/2026 at 1:46 PM, Licensed Practical Nurse 8 (LPN), explained the procedure for unwitnessed fall follow through. LPN 8 explained staff assess the resident for any injuries, attempt to figure out the cause of the fall, start neurological assessments, then did neuros every 15mins afterward x4, then neurological assessment (neuros) every hour x4, and then neuros every shift x 72 hours.

The nurse would contact the provider and family.

The nurse was to do a skin assessment, post fall assessment, dehydration assessment, and document findings in a progress note. In an interview, on 03/27/2026 at 11:12 AM, DIrector of Nursing (DON) indicated neuros were to be done after an unwitnessed fall every 15 minutes for the first hour, then hourly x4, and then every shift x3 days.

Medical provider and family were to be notified.

After each fall an intervention should be put into the care plan. A morse fall scale assessment should be done. On 3/30/26 at 10:15am, a review of Resident 6's neurological assessments indicated the following assessments were not completed for an unwitnessed fall:11/29/25 23:00 and 23:5811/30/25 1:03am and 2:00am 12/1/25 2nd shft12/2/25 3rd shift 2. Resident 13's record review began on 3/25/26 at 11:42am diagnosis included epilepsy, dementia, and diabetes.Resident 13's current care plan, dated 2/3/25, indicated he was at risk of falling.

With a goal for fall to be minimized using care plan interventions to prevent injury through next review period.

One intervention was to follow facility fall protocol. A review of neuro assessments indicated 9/16/25, 9/17/25 and 9/18/25 were missing 2nd shift neurological assessments.A review of neuro assessments, dated 12/20/25, was missing assessments at the following times; 10:20am, 10:35am, 10:50am, 11:05am, 12:05pm, 1:05pm, 2:05pm, and 3:05pm.A review of 12/21/25 neuro assessments indicated there were missing assessments for 1st and 2nd shift. A review of neuro assessments, dated 3/17/25, indicated no neuro assessment, were documented for the following times 4:15am, 4:30am, 5:30am.

There were no neurological assessments every shift x72 hours for the dates of 3/18/25, 3/19/25, and 3/20/25.3. Resident 29's record review began on 3/25/26 at 12:41pm.

Diagnosis included dementia, abnormal posture, and diabetes.In an interview, on 03/27/2026 at 2:04 PM, the DON indicated she was unable to locate neuros for the following falls: 4 on 11/10/25, 1 on 11/11/25, 1 on 11/12/25 and two on 11/13/25.

The DON indicated the nurses began the 10/24/25 fall neurological assessments.

She was unsure what happened the next three days.

She was unable to find neuro assessments dated 10/25 through 27/2025 for Resident 29. A current policy, titled Falls Clinical Protocol, dated 11/16/17 was provided by the Executive Director on 3/26/26 at 11:29am indicated the following: In addition, the nurse shall assess and document/report the following:.Vital signsRecent injury, especially fracture or head injuryMusculoskeletal function, observing for change in normal range of motion, weight bearing, etc.Change in cognition or level of consciousnessNeurological statusPainFrequency and number of falls Precipitating factors, details on how fall occurredAll current medications, especially those associated with dizziness or lethargyAll active diagnosis.

There were no specific directions of how often neurological assessments were to be done in the policy. 410 IAC (Indiana Administrative Code) 3.1-45(a)

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Byron Health Center 1661 Beacon Street Fort Wayne, IN 46805

disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on

investigated for 1 of 1 resident reviewed (Resident 77).Findings include:Resident 77's record was reviewed on 03/25/2026 at 11:25 AM.

Diagnoses included Alzheimer's disease, anxiety, and depression.A current admission Minimum Data Set (MDS) assessment, dated 1/27/2026, indicated Resident 77 had a Basic Interview for Mental Status (BIMS) score of 4 (cognitively impaired).Resident 77's current care plan, dated 4/26/26, titled depression with history of suicidal ideation, indicated Resident 77 had a problem of depression.

Interventions included redirecting Resident 77 when making comments related to suicidal ideation and notifying a supervisor immediately when suicidal comments were made.A progress note, dated 3/9/2026, at 4:24 PM, indicated Resident 77 told Volunteer 4 she had nothing to live for and wanted to kill herself. No additional progress notes regarding suicidal ideation were available for review. In an interview, on 03/27/2026 at 11:07 AM, the Director of Nursing (DON) indicated any resident verbalizing suicidal ideation should be asked if they had a plan to harm themselves.

The DON indicated the resident's care plan for those types of issues should be reviewed and followed.

The DON indicated a resident voicing suicidal ideation may be sent out for inpatient psychiatric care by the nurse practitioner if deemed appropriate. In an interview, on 03/27/2026 at 11:38 AM, Qualified Medicine Aide (QMA) 3 indicated upon a verbalization of suicidal ideation, staff should contact a supervisor and remain with the resident ensuring safety until given further instructions. QMA 3 indicated she was not aware of any recent statements by any residents.

QMA 3 indicated she regularly worked on the unit Resident 77 resided on. QMA 3 indicated upon admission several months ago, Resident 77 was confused, and made suicidal remarks. QMA 3 indicated she was not aware of Resident 77's suicidal verbalization on the 9th of this month. In an interview, on 03/27/2026 at 11:45 AM, Life Enrichment Specialist (LCS) 2 indicated volunteers filled out a visit log describing 1 to 1 visits conducted with residents. LCS 2 indicated she collected 1 to 1 visit logs and entered visit notes into the computer on a weekly basis, LCS 2 indicated she read the statement of suicidal ideation on 3/18/2026 when she entered the log into the computer. LCS 2 indicated she should have reported the statement of suicidal ideation to the Resident Engagement Specialist as soon as she was aware. A document titled 1:1 log, provided by the Administrator on 03/27/2026 12:40 PM, indicated during a 3-minute visit with Volunteer 4 on 3/9/2026, Resident 77 indicated she had nothing to live for and wanted to kill herself . In an interview, on 03/27/2026 11:57 AM, Volunteer 4 indicated Resident 77 told him she had nothing to live for and wanted to kill herself on 3/9/2026.

Volunteer 4 indicated he said kind words to Resident 77 and offered support.

Volunteer 4 indicated he was unable to immediately find the unit nurse, so he went to the adjacent unit and reported the verbalization to the staff on that unit. In an interview, on 03/27/2026 1:13 PM, the Administrator indicated upon a report of suicidal verbalizations, staff should notify the nursing supervisor, initiate policy interventions such as performing a [NAME] suicide risk assessment and ensuring resident safety.

The Administrator indicated results of the assessment should be reported to the provider and staff should follow any ensuing orders The Administrator indicated she had just become aware of the verbalization and was investigating where the communication lapse had occurred.A current policy, titled Suicide Threats, dated 2/28/2018, provided by the Administrator on 3/27/2026 at 12:51 PM, indicated staff should report any threats of suicide immediately to the Nurse Supervisor while maintaining supervision of the resident.

The Nurse Supervisor or Resident Engagement Specialist should complete a Columbia Suicide Severity Rating Scale for the resident and report findings to the provider.

Any applicable provider orders should be followed, and the details of the situation should be documented.410 IAC (Indiana Administrative Code) 16.2-3.1

155364 03/31/2026

Byron Health Center 1661 Beacon Street Fort Wayne, IN 46805

During an observation of the kitchen, on 3/25/2026 at 9:12 AM, a set of keys was observed sitting on the steam table serving area.

The handwashing sink was observed to contain brown chunks and white debris.

The grill was observed to have black buildup between the grill grates and black char buildup underneath the grill grates.

The grill foil was observed to have a large accumulation of black buildup.A review of the weekly cleaning list provided by the Executive Director on 3/26/2026 indicated the grill foil, grill grates and shelving were cleaned by the AM [NAME] on Monday, 3/23/2026.

The cleaning list indicated the grill and stovetop were cleaned by the PM [NAME] on Tuesday, 3/24/2026.

During an interview, on 3/25/2026 at 9:25 AM, the DM indicated the black buildup was from cooking breakfast.

The DM indicated staff may have had food on their hands when using the handwashing sink.

The DM also indicated the keys should not have been left on the kitchen serving area.A current facility policy, Cleaning and Sanitizing of Kitchen Equipment, dated 4/26/2025, provided by the DM on 3/26/2026 at 11:19 AM, indicated all food service equipment and food-contact surfaces shall be cleaned and sanitized between tasks and at a frequency that prevents contamination.410 Indiana Administrative Code (IAC) 16.2-3.1-21(i)(2) and (3) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

155364 03/31/2026

Byron Health Center 1661 Beacon Street Fort Wayne, IN 46805

corrective plans of action.

implementation of interventions to maintain kitchen sanitation for 103 of 103 residents residing in the

indicated the facility was cited for F-F812.

The citation included maintaining sanitation, open food items, labeling of food, and food open being dated.During an observation, on 03/25/2026 at 9:12 AM, in the kitchen there was a bag of frozen chips and cinnamon rolls in freezer open to air no open dates.

Beef base without an open date, elbow macaroni in clear bin without a date, white bread, whole wheat bread, hamburger buns, and sub buns without dates.

Dill weed seasoning without a lid, open to air.

These were similar issues compared to the recertification survey dated 5/19/25 with F-F812 being cited 2 years in a row. In an interview, on 3/31/26 at 9:59am, the Executive Director (ED) indicated herself and the Assistant Executive Director did various observations of the kitchens and kitchenettes of the neighborhoods.

The ED did not have any documentation of the observations.

The ED indicated the committee had been working on food temperatures, labeling, dating, and cleanliness since last April.

The facility had some change over in the dietary aids and felt this corrected the problem until annual survey results. No policy was given at time of exit.

155364 03/31/2026

Byron Health Center 1661 Beacon Street Fort Wayne, IN 46805

(Resident 79).Findings include:During an observation on 3/25/2026 at 10:11 AM, the following was

liquid inside hanging by the handle on the trash bin, dated 3/19/2026.During an observation on 3/26/2026 at 1:27 PM, the following was observed: Resident 79 was sitting in a recliner in his room and had a portable urinal bottle with yellow liquid inside hanging by the handle on the trash bin.During an observation on 3/27/2026 at 12:47 PM, the following was observed: Resident 79 was sitting in a recliner in his room and had a portable urinal bottle with yellow liquid inside hanging by the handle on the trash bin. A glove, plastic drinking cup, piece of folded paper and three paper towels were observed in the trash can.During an observation on 3/27/2026 at 1:15 PM, the following was observed: Resident 79 had a portable urinal sitting on top of his table.

Also on the table were three remote controls and a piece of folded paper.Resident 79's record was reviewed on 3/25/2026.

Diagnoses included altered mental status and diabetes mellitus.A review of Resident 79's current care plan did not indicate the resident required a urinal to be kept at the bedside or within immediate reach while seated in a recliner.In an interview on 3/27/2026 at 12:47 PM, Certified Nursing Assistant (CNA) 9 indicated the portable urinal hanging on the trash can was an infection control concern. CNA 9 indicated she was unsure where to place the urinal, as the resident's table had items on it. CNA 9 indicated Resident 79 went to the bathroom often and liked to have the urinal close by.

Certified Nursing Assistant (CNA) 9 indicated she would dump the urinal and provide a fresh urinal.In an interview on 3/27/2026 at 12:47 PM, the Director of Nursing (DON) indicated that after a resident used a portable urinal, staff were expected to clean it and place it on the back of the toilet.

The DON indicated clean portable urinals should be stored on the back of the toilet when not in use.

The DON indicated this was the first time she had been made aware of Resident 79 storing the urinal on the trash can.

The DON indicated the care plan should reflect if a resident preferred to have the urinal stored close by.

The DON indicated Resident 79's care plan did not indicate such a preference.A current policy dated 10/2010, provided by the Executive Director, indicated: If the resident keeps his urinal at his bedside, check it frequently.

Empty and clean it as necessary.

Note on the resident's care plan his request to keep the urinal at his bedside.

Remove urinal.

Place it on a paper towel on the bedside stand.

Cover the urinal immediately with a urinal cover or paper towel.

Clean wash basin and return to designated storage area.410 IAC (Indiana Administrative Code) 16.2-3.1-18(a)