Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 1
May 29, 2025
Visit Reason
This visit was conducted for the investigation of complaint IN00459224 regarding allegations of misappropriation of residents' narcotic medications.
Findings
The facility failed to ensure residents were free from misappropriation of pharmaceutical services for 2 of 3 residents reviewed. Narcotic medications for Resident D and Resident G went missing after delivery from the pharmacy, causing missed physician-ordered routine medications. The facility implemented re-education and auditing procedures to prevent recurrence.
Complaint Details
Complaint IN00459224 was substantiated with federal/state deficiencies cited related to misappropriation of medications. The facility investigation confirmed missing narcotic medications and incomplete narcotic counts by nursing staff.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure residents were free from misappropriation of narcotic medications, resulting in missing medications and missed doses for Resident D and Resident G. | SS=D |
Report Facts
Census: 46
Total Capacity: 46
Medication doses missing: 30
Audit period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Khushali Shah | Administrator | Signed report and involved in facility administration |
| RN 2 | Interviewed regarding missing narcotic medication sheets and narcotic count procedures | |
| RN 4 | Reported missing 30 Norco medications for Resident G to Director of Nursing | |
| RN 7 | Received medications from pharmacy and left them for LPN 9 to secure | |
| LPN 9 | Documented receipt of medications and secured them in medication cart | |
| Facility Administrator | Interviewed and provided facility policy on controlled substances | |
| Director of Nursing | Involved in investigation and auditing of controlled substances |
Inspection Report
Re-Inspection
Census: 46
Capacity: 117
Deficiencies: 0
Apr 1, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance following previous surveys on 01/15/25 and 03/03/25.
Findings
At this second Post Survey Revisit, Lodge of the Wabash was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with a fire alarm system and hard wired smoke detectors throughout.
Report Facts
Total licensed capacity: 117
Certified beds: 70
Census: 46
Inspection Report
Re-Inspection
Census: 49
Capacity: 117
Deficiencies: 1
Mar 3, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey due to previous deficiencies, including lack of a 2 hour fire-rated separation.
Findings
At this PSR, the facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements due to failure to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE) testing. The deficiency was previously cited and proper corrective action had not been implemented.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to conduct required maintenance and maintain documentation of inspections for Patient Care Related Electrical Equipment (PCREE), including electric beds, oxygen concentrators, and air pumps. | SS=F |
Report Facts
Total certified beds: 70
Census: 49
Total capacity: 117
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Smyth | RDO | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Life Safety
Census: 51
Capacity: 117
Deficiencies: 7
Jan 15, 2025
Visit Reason
The inspection was conducted as an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey to assess compliance with emergency preparedness and life safety requirements, including fire safety and facility maintenance.
Findings
The facility was found not in compliance with emergency preparedness requirements due to outdated agreements with other LTC facilities. Life safety deficiencies included lack of documentation for emergency lighting testing, missing semiannual kitchen exhaust inspections, incomplete fire alarm system visual inspections, a hole in the laundry room ceiling affecting sprinkler function, incomplete fire drill documentation and timing, and lack of testing and documentation for patient care related electrical equipment.
Severity Breakdown
SS=F: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness policies included updated arrangements with other LTC facilities to receive residents in case of operational limitations. | SS=F |
| Failed to provide documentation for monthly 30-second and annual 90-minute testing of battery powered emergency lighting. | SS=F |
| Failed to provide documentation of semiannual inspection of kitchen exhaust system as required by NFPA 96. | SS=F |
| Failed to maintain semiannual visual inspections of fire alarm system devices such as smoke detectors and heat detectors. | SS=F |
| Failed to maintain ceiling in laundry room to allow sprinkler heads to function properly due to a 4x3 inch hole. | SS=E |
| Failed to provide quarterly fire drill documentation for one shift during one quarter and failed to hold fire drills at varied times for all shifts. | SS=F |
| Failed to conduct required maintenance and maintain documentation for patient care related electrical equipment testing. | SS=F |
Report Facts
Certified beds: 70
Census: 51
Total capacity: 117
Fire drill missing documentation: 1
Hole size: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Khushali Shah | Administrator | Named in relation to exit conferences and oversight of corrective actions |
| Maintenance Director | Named in relation to findings on emergency lighting, fire alarm inspections, kitchen exhaust, sprinkler maintenance, fire drills, and electrical equipment testing |
Inspection Report
Recertification
Census: 50
Capacity: 50
Deficiencies: 11
Jan 14, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Nursing Home Complaint IN00450791.
Findings
The facility was found to have multiple deficiencies including failure to provide proper notice of transfer/discharge, inadequate bed hold policy notification, inadequate fall prevention and notification, respiratory care deficiencies, nursing competency issues, improper medication storage, infection control lapses, inadequate dementia care, and environmental sanitation issues.
Complaint Details
Complaint IN00450791 was investigated, with federal/state deficiencies related to the allegations cited at F695.
Severity Breakdown
SS=D: 7
SS=C: 1
SS=E: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure notice of transfer or discharge was given to residents or representatives for 3 of 3 residents reviewed for hospitalizations. | SS=D |
| Failed to ensure bed hold policy notification was given to residents or representatives for 3 of 3 residents reviewed for hospitalizations. | SS=D |
| Failed to provide adequate supervision and prevent falls for 2 of 6 residents reviewed for accidents; fall assessments and care plans were not updated timely and family was not notified. | SS=D |
| Failed to ensure necessary respiratory care and services for 3 of 3 residents; oxygen tubing not changed, portable tanks not checked, concentrator filters not cleaned. | SS=D |
| Failed to ensure competent nurse staffing; medication not administered, wound dressing initiated without order, bandage left on resident for six days. | SS=D |
| Failed to ensure posted nurse staffing sheets were posted and contained correct information daily for 6 of 6 days reviewed. | SS=C |
| Failed to ensure person-centered dementia treatment and services for 2 of 4 residents reviewed for dementia care. | SS=D |
| Failed to ensure proper storage of medications; narcotic boxes not double locked in 2 of 3 medication carts. | SS=D |
| Failed to ensure infection control practices; gloves not changed and hand hygiene not performed between dirty and clean tasks during peri care, hand hygiene not performed prior to medication administration, inadequate hand washing duration. | SS=E |
| Failed to ensure a sanitary and home-like environment; uncovered personal items and linens, dusty vents and fans, soiled toilets, missing paint and baseboards, uncovered toilet seat riser on floor, and improper refrigerator temperature logs. | SS=E |
| Failed to ensure a qualified Infection Preventionist worked at least part-time; interim IP lacked infection control certification. | SS=E |
Report Facts
Survey dates: January 2, 3, 8, 9, 13, 14, 2025
Census: 50
Total Capacity: 50
Residents reviewed for transfer/discharge notice: 3
Residents reviewed for bed hold policy: 3
Residents reviewed for falls: 6
Falls for Resident 44: 7
Residents reviewed for respiratory care: 3
Medication carts with unlocked narcotic boxes: 2
Days with missing refrigerator temperature logs: 12
Staff education completion dates: 2025-01-15 to 2025-02-12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 9 | Licensed Practical Nurse | Named in findings related to missing transfer/discharge paperwork and bed hold paperwork |
| Registered Nurse 3 | Registered Nurse | Named in respiratory care and medication administration findings |
| Certified Nurse Aide 37 | Certified Nurse Aide | Named in infection control and incontinence care findings |
| Certified Nurse Aide 41 | Certified Nurse Aide | Named in infection control and incontinence care findings |
| Clinical and Quality Consultant | Provided multiple interviews and policies related to deficiencies | |
| Assistant Director of Nursing | Assistant Director of Nursing | Named as interim Infection Preventionist and in interviews regarding deficiencies |
| Director of Nursing | Director of Nursing | Named as Infection Preventionist on leave |
| Maintenance Supervisor | Named in environmental and refrigerator temperature findings | |
| Housekeeping Supervisor | Named in environmental and refrigerator temperature findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 14, 2025
Visit Reason
Paper compliance review related to the Recertification, State Licensure, and Investigation of Complaint IN00450791 survey.
Findings
Lodge of Wabash was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification, State Licensure, and Investigation of Complaint IN00450791 survey.
Inspection Report
Renewal
Deficiencies: 0
Feb 13, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure survey completed on December 14, 2023.
Findings
The Lodge of Wabash was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 52
Capacity: 117
Deficiencies: 0
Feb 12, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/09/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered except for a garage used as a maintenance shop and storage.
Report Facts
Certified beds: 70
Inspection Report
Life Safety
Census: 50
Capacity: 117
Deficiencies: 4
Jan 9, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and 42 CFR 483.73 for Emergency Preparedness.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies including failure to ensure corridor doors properly latched, failure to conduct quarterly fire drills on the second shift for one quarter, and incomplete documentation and testing of the emergency generator including missing load test details, transfer times, and cool down periods.
Severity Breakdown
SS=D: 1
SS=F: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of over 30 resident room corridor doors were provided with means suitable for keeping the door closed and latched, affecting rooms 216 and 408. | SS=D |
| Failed to conduct quarterly fire drills on the second shift for 1 of 4 quarters in 2023. | SS=F |
| Failed to maintain complete written records of monthly generator load testing for 12 of the past 12 months, including missing load percentage, amps, voltage readings, and transfer times. | SS=F |
| Failed to ensure the emergency generator was allowed a 5 minute cool down period after load testing. | SS=F |
Report Facts
Certified beds: 70
Total capacity: 117
Census: 50
Deficiency count: 4
Fire drill quarters missed: 1
Generator load tests missing details: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Greg Matheis | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Maintenance Supervisor | Interviewed and confirmed deficiencies related to corridor doors and generator testing | |
| Administrator | Interviewed and involved in exit conference regarding findings | |
| Maintenance Director | Educated on corridor door requirements and generator testing procedures |
Inspection Report
Annual Inspection
Census: 51
Capacity: 51
Deficiencies: 3
Dec 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00415576. The visit included a State Residential Licensure Survey.
Findings
The facility was found to have deficiencies including failure to provide respiratory care consistent with professional standards for one resident, failure to serve hot food at appropriate temperatures for one lunch tray, and failure to prepare or submit an Alzheimer's/Dementia Special Care Unit disclosure form. No deficiencies related to the complaint allegations were cited.
Complaint Details
Complaint IN00415576 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a resident who needed respiratory care was provided such care consistent with professional standards; oxygen was not given as ordered and the oxygen concentrator and filter were not cleaned (Resident 12). | SS=D |
| Failed to provide hot food for one of one lunch trays sampled; food that was supposed to be served hot was served cold (300 hall and 400 hall). | SS=D |
| Failed to prepare or submit an Alzheimer's/Dementia Special Care Unit disclosure form as required by state regulations. | SS=D |
Report Facts
Census: 51
Total Capacity: 51
Oxygen flow rate: 2
Oxygen flow rate: 3
Food temperature: 102.6
Residents in memory care unit: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Greg Matheis | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| RN 16 | Registered Nurse | Provided CNA assignment forms indicating Resident 12 was on 2 LPM oxygen |
| Corporate Consultant 1 | Observed oxygen concentrator settings, provided policies, and indicated need for order clarification | |
| RN 23 | Registered Nurse | Indicated activities on the memory care unit differ from other units |
| Dietary Manager | Interviewed regarding food temperature expectations and education provided to staff | |
| Hospice RN | Interviewed regarding communication and oxygen orders for Resident 12 | |
| Director of Nursing | DON | Indicated facility had a memory care unit and discussed dementia disclosure agreement |
Inspection Report
Re-Inspection
Census: 49
Capacity: 49
Deficiencies: 0
Jul 18, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00409392 and IN00401358 completed on 2023-05-31.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaints IN00409392 and IN00401358. Both complaints were corrected.
Complaint Details
This visit was related to complaints IN00409392 and IN00401358, both of which were corrected.
Report Facts
Census SNF/NF: 49
Total Capacity: 49
Census Payor Type Medicaid: 39
Census Payor Type Other: 10
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 1
May 30, 2023
Visit Reason
This visit was conducted to investigate complaints IN00409392 and IN00401358 concerning the facility's compliance with federal and state regulations related to resident safety and accident prevention.
Findings
The facility failed to ensure a resident was free from accidents, specifically failing to implement fall protocols after a resident sustained a hip fracture and had a subsequent fall. Documentation and communication regarding the falls were inadequate, and the facility did not follow its own policies for incident reporting and family/physician notification.
Complaint Details
Complaint IN00409392 and IN00401358 were investigated. The allegations were substantiated with deficiencies cited at F689 related to failure in fall prevention and incident reporting. The deficient practice was corrected on 5/25/23 prior to the survey.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free of accident hazards and to provide adequate supervision and assistance devices to prevent falls. | SS=G |
Report Facts
Census: 52
Total Capacity: 52
Medicaid Census: 44
Other Payor Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding fall incident and facility policies | |
| LPN 6 | Resident's nurse on 5/24/23 who completed fall incident report | |
| CNA 5 | Assisted resident on 5/24/23 and reported falls |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Jan 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399792.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00399792 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 54
Total Capacity: 54
Medicare Census: 4
Medicaid Census: 42
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Oct 25, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00373765.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00373765 was substantiated; however, no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 52
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 8
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