Cycle 1
Health 2025-08-05 · Fire 2025-08-05
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fort Wayne, IN
Golden Years Homestead
2-star overall rating with 2-star inspections with $15,646 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3136 Goeglein Rd, Fort Wayne, IN
(260) 749-9655
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
111
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Greencroft Communities
Operator or chain grouping
Approved since
2005-12-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
3.02
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.03
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,369
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9978
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.22
Baseline 18.26% · Performance 20.40% · Measure score 2.22 · Achievement 2.22 · Improvement 0
Healthcare-associated infections
3.87
Baseline 6.16% · Performance 6.68% · Measure score 3.87 · Achievement 3.87 · Improvement 0
Total nurse turnover
8.67
Baseline 45.08% · Performance 28.26% · Measure score 8.67 · Achievement 8.67 · Improvement 7.81
Adjusted total nurse staffing
3.12
Baseline 3.95 hours · Performance 3.96 hours · Measure score 3.12 · Achievement 3.12 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.17% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 11.7% · Lower 95% interval 7.57% |
| Discharge to community | 48.31% |
50.57%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 42.53% · Lower 95% interval 39.96% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 76.47% |
95.27%
18.8 pts worse
|
Numerator 39 · Denominator 51 |
| Falls with major injury | 1.96% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 51 |
| Discharge self-care score | 71.79% |
53.69%
18.1 pts better
|
Numerator 28 · Denominator 39 |
| Discharge mobility score | 46.15% |
50.94%
4.8 pts worse
|
Numerator 18 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 51 · Adjusted rate 1.87% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 4.44% |
8.2%
3.8 pts worse
|
Numerator 8 · Denominator 180 |
| Staff flu vaccination coverage | 38.42% |
42%
3.6 pts worse
|
Numerator 68 · Denominator 177 |
| Discharge function score | 61.54% |
56.45%
5.1 pts better
|
Numerator 24 · Denominator 39 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 21 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 22.73% |
25.2%
2.5 pts worse
|
Numerator 5 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
93.6%
2.5 pts worse
|
93.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 74.1% · Q2 94.8% · Q3 100.0% · Q4 97.4% · 4Q avg 91.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
95.4%
2.4 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.6% |
3.8%
3.8 pts worse
|
3.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 7.8% · Q3 6.7% · Q4 6.4% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
24.6%
19.4 pts better
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.9% · Q3 1.5% · Q4 9.9% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
5.6%
2.7 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 13.6% · Q3 5.1% · Q4 6.7% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.7% |
23.5%
4.8 pts better
|
19.6%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 16.9% · Q3 18.3% · Q4 23.3% · 4Q avg 18.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
14.8%
0.4 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 14.0% · Q3 12.7% · Q4 16.1% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.9% |
13.3%
13.6 pts worse
|
16.3%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 20.4% · Q3 28.2% · Q4 34.8% · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.6% |
11.7%
18.9 pts worse
|
14.9%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 30.5% · Q3 30.0% · Q4 37.5% · 4Q avg 30.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
1.2%
3.9 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 7.8% · Q3 5.4% · Q4 5.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.5% |
24.2%
10.3 pts worse
|
19.8%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 35.9% · Q3 28.6% · Q4 32.1% · 4Q avg 34.5% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.1%
0.6 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.1% · Q3 2.3% · Q4 1.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.8% |
81.6%
5.2 pts better
|
81.7%
5.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 73.7% · Q2 88.5% · Q3 92.6% · Q4 90.0% · 4Q avg 86.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
10.5%
3.1 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 6.7% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.8% |
79.0%
3.2 pts worse
|
79.7%
3.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
22.4%
4.6 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 15.6% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-23 · Fire 2024-09-23
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-09-12 · Fire 2023-09-12
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-08-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-05
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-10-10
C · Minimal harm
2025-08-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-10
F · Potential for more than minimal harm
2024-09-23
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-09-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-09-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-09-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-09-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-09-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-05
C · Minimal harm
2024-09-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-05
F · Potential for more than minimal harm
2023-09-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-08-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-07-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-20
D · Potential for more than minimal harm
2025-05-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-07
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-13
E · Potential for more than minimal harm
2024-09-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-23
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-04-04
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-09
J · Immediate jeopardy
2024-01-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-13
E · Potential for more than minimal harm
2024-01-30
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-02-13
D · Potential for more than minimal harm
2023-09-12
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-10-18
Penalties and ownership
What sits behind the stars
$15,646
2024-01-30
Fine
Fine · fine $15,646
Fine
Ownership
Woodlawn Hospital
5% Or Greater Direct Ownership Interest · Organization
Baltes, Christopher
Operational/Managerial Control · Individual
Bullion, George
Operational/Managerial Control · Individual
Bullion, George
Corporate Director · Individual
Carpenter, Michael
Operational/Managerial Control · Individual
Carpenter, Michael
Corporate Director · Individual
Davis, Hugh
Operational/Managerial Control · Individual
Davis, Hugh
Corporate Director · Individual
Dean, Dale
Operational/Managerial Control · Individual
Dean, Dale
Corporate Director · Individual
Elick, Cynthia
Operational/Managerial Control · Individual
Elick, Cynthia
Corporate Director · Individual
Fisher, Alan
Operational/Managerial Control · Individual
Fisher, Alan
Corporate Officer · Individual
Golden Years Homestead, Inc
Operational/Managerial Control · Organization
Heyde, Alison
Corporate Director · Individual
Johnson, Terri
Corporate Director · Individual
Mcintosh, Ray
Operational/Managerial Control · Individual
Mcintosh, Ray
Corporate Director · Individual
Mellinger, Gregory
Corporate Director · Individual
Misner, Donna
Operational/Managerial Control · Individual
Misner, Donna
Corporate Director · Individual
Olinski, Lynda
Operational/Managerial Control · Individual
Olinski, Lynda
Corporate Director · Individual
Schmidt, Don
Operational/Managerial Control · Individual
Schmidt, Don
Corporate Director · Individual
Shafer, Shauna
Operational/Managerial Control · Individual
Shaw, Doug
Operational/Managerial Control · Individual
Shaw, Doug
Corporate Director · Individual
Smith, Linda
Operational/Managerial Control · Individual
Smith, Linda
Corporate Director · Individual
Vanwyngarden, Andrea
Operational/Managerial Control · Individual
Vanwyngarden, Andrea
Corporate Director · Individual
Villarreal, Jeannine
Operational/Managerial Control · Individual
Villarreal, Jeannine
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Chateau Rehabilitation And Healthcare Center
Fort Wayne, IN
2-star overall rating with 1-star inspections with $109,257 in total fines with 9 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Waters Of Fort Wayne Skilled Nursing Facility, The
Fort Wayne, IN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Majestic Care Of New Haven
New Haven, IN
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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