Kingston Health Center of Fort Wayne

In the surveyor’s words

From the most serious findings on record at Kingston Health Center of Fort Wayne, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Feb 9, 2023

  Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed were free from a significant medication error. The error resulted in respiratory distress, need for emergent treatment and the potential for death (Resident D). The Immediate Jeopardy began on 1/11/23 when Resident D was administered 100 milligrams of Morphine by mouth, 20 times the amount of medication prescribed. The facility failed to assess and monitor the resident for side effects after identifying the medication error. This resulted in respiratory distress and need for emergent treatment. The Administrator was notified of the Immediate Jeopardy on February 8, 2023 at 4:09 P.M. […]

• No harm, potential for more than minimal, patternF812Nov 20, 2025

  Based on interview, observation and record review the facility failed to follow sanitation methods to maintain a clean environment in the kitchen area. 107 of 107 residents who resided in the facility ate food prepared in the kitchen.Findings include:During an observation, on 11/19/25 at 10:20 AM, 22 plus live gnats were observed in the dining room corner, on the opposite wall from the dishwasher. There were 3 carts covered in dried yellow and white liquid. There were also 3 carts of leftover food from breakfast waiting to be washed.During an interview, on 11/19/25 at 10:21 AM, the Dietary Manager (DM) indicated pest control had treated the gnats and it had resolved. The DM indicated there had been increased cleaning of the area and the carts were cleaned nightly. […]

• No harm, potential for more than minimal, patternF925Nov 20, 2025

  Based on interview, observation and record review the facility failed to follow sanitation methods to prevent pests. 107 of 107 residents who resided in the facility ate food prepared in the facility kitchen.Findings include:During an observation on 11/19/25 at 10:20 AM, 22 plus live gnats were observed in the dining room corner, on the opposite wall of the dishwasher. There were 3 carts covered in dried yellow and white liquid. There were also 3 carts of leftover food from breakfast waiting to be washed.During an interview on 11/19/25 at 10:21 AM, the Dietary Manager (DM) indicated pest control had treated the gnats and it had resolved. The DM indicated there had been increased cleaning of the area and the carts were cleaned nightly. […]

• No harm, potential for more than minimal, patternF726Jun 25, 2025

  Based on record review and interview the facility failed to ensure a license was current for 1 of 159 licensed staff. (Qualified Medical Assistant (QMA) 9). Findings include: A review of the facility licensure book, on [DATE] at 12:PM, indicated QMA 9's license expired on [DATE]. In an interview, on [DATE] at 1:45PM, the Administrator was informed QMA 9's license was expired. In an interview, on [DATE] at 10:30AM, the administrator provided QMA 9's license renewed [DATE]. The Administrator was unsure if QMA 9 had worked any hours while the license was expired. In an interview, on [DATE] at 11:15 AM, the DON indicated the dates QMA 9 worked in the facility without a license was [DATE] and [DATE]. […]

• No harm, potential for more than minimal, patternF812Jun 25, 2025

  Based on observation and interview, the facility failed to ensure safe sanitization parameters were maintained for cleaning solutions used in the kitchen. 106 of 109 residents eat food prepared in the facility kitchen. Findings include: During an observation, on 06/19/25 at 09:15 AM, the following was observed: the Dietary Manager (DM) performed dipstick testing on the red sanitization bucket in the main kitchen. The solution did not cause the test strip to change color. The DM indicated the test strip should change color to confirm the solution is a minimum of 150ppm (parts per million). […]