Golden Years Homestead
Inspection Findings
F-Tag F0697
F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
resident on [DATE REDACTED]. Resident B's POA indicated she was unable to attend but requested a phone call
during the visit. Resident B's POA indicated she did not receive a call from the doctor nor the facility regarding medication changes for Resident B. Resident B's POA indicated on [DATE REDACTED] evening she visited Resident B, indicated she seemed spicy. Resident B's POA indicated when Resident B seemed spicy, this meant her medications were off. Resident B's POA indicated she requested a printed medication list from
the nurse and upon review, she observed a new order of morphine 15 mg to be given every 12 hours, twice
a day. Resident B's POA indicated she was not aware of the new order, requested the nurse hold the medication for the evening so she could talk to the doctor in the morning. Resident B's POA indicated she did not want Resident B to receive morphine. Resident B's POA indicated on [DATE REDACTED] morning, she received
a call from the facility indicating Resident B had passed away. Resident B's POA indicated the nurse had indicated Resident B did receive the ordered morphine the night before.During an interview on [DATE REDACTED] at 11:25AM. The DON, Physical Therapist 4 and Social Service Director (SSD) indicated a care plan meeting was held on [DATE REDACTED] with Resident B, Resident B's POA and family. The SSD and BOM indicated they did not recall discussion regarding the doctor visit on [DATE REDACTED]. The SSD indicated if a Resident had BIMS less than 12 the POA would be updated with any changes regarding medications or care. SSD indicated the Doctor or Nurse Practitioner visit new admission residents daily for the first week. The SSD indicated Resident B's POA should have been notified of medication changes. The DON indicated residents are monitored every 2 hours by staff. The DON indicated the staff did not document monitoring completion.During an interview on [DATE REDACTED] at 1:56 PM, Registered Nurse (RN) 3 indicated she had worked
on [DATE REDACTED] evening shift into [DATE REDACTED] morning. RN 3 indicated she was not told to hold any orders in report.
RN 3 indicated on [DATE REDACTED] was the first time she had cared for Resident B, but she was alert and orientated.
RN 3 indicated she administered morphine as ordered at 9 PM, then checked on the resident around 12 AM and again at 2: 30 AM. RN 3 indicated Resident B's vital signs were within normal range at 12 AM. RN 3 indicated around 5 AM the aide notified the nurse of Resident B's death. RN 3 indicated when family requested medication to be held, she documented the request and notified the doctor. RN 3 indicated after administering pain medications she followed up on the effectiveness within the hour and monitored for adverse side effects.During an interview on [DATE REDACTED] at 1:35 PM, RN 5 indicated staff monitored for adverse side effects of pain medications. RN 5 indicated new medications, such as morphine, required additional monitoring. RN 5 indicated she completed a vital assessment 30 minutes to 1 hour after the administration of morphine and continued to frequently check on the residents to ensure no adverse side effects occurred.
RN 5 indicated resident's POA were notified of medication changes and when a hold request was made,
the nurse documented the request. RN 5 indicated she notified the doctor of hold request as well.A policy, last revised [DATE REDACTED], titled Medication Administration, was provided by the Administrator on [DATE REDACTED] at 10 AM. The policy indicated to monitor adverse side effects.According to the World Health organization article, dated [DATE REDACTED], titled opioid overdose, opioids have a long half-life and can build up in the system over time or with concurrent use in combination doses. Risk factors for opioid overdose include using opioids in combination with each other or other substances, and chronic conditions such as liver or kidney disease.This finding relates to Intake 2652223.3.1 - 37 (a)
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GOLDEN YEARS HOMESTEAD in FORT WAYNE, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FORT WAYNE, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GOLDEN YEARS HOMESTEAD or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.