Inspection Reports for
Lodge of the Wabash
723 E RAMSEY RD, VINCENNES, IN, 47591
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
129% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
100% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding missing narcotic medications at the facility.
Complaint Details
This citation relates to complaint IN00459224. The complaint involved missing narcotic medications for Residents D and G, with substantiation based on facility investigation and observations.
Findings
The facility failed to ensure residents were free from misappropriation of pharmaceutical services, resulting in missing narcotic medications for two residents, causing missed physician-ordered routine medications. The investigation revealed incomplete narcotic medication counts and missing count sheets, preventing an exact total of missing medications from being determined.
Deficiencies (1)
F 0602: The facility failed to protect residents from wrongful use of their belongings or money by not safeguarding narcotic medications, resulting in missing doses for two residents. Nursing staff did not complete required narcotic counts every shift, and count sheets were missing, leading to an inability to determine the total missing medications.
Report Facts
Medication doses received: 58
Medication doses received: 42
Medication doses signed out: 28
Medication doses signed out: 12
Medication cards counted: 34
Medication cards counted: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Indicated that full sheets of narcotic medications had recently gone missing and described narcotic count procedures | |
| RN 4 | Reported missing 30 Norco medications for Resident G to the Director of Nursing | |
| RN 7 | Received medication from pharmacy and left it for LPN 9 to secure in medication cart | |
| LPN 9 | Documented receipt of medication cards and secured them in locked medication cart | |
| Facility Administrator | Interviewed and indicated missing narcotic medications and count sheet issues | |
| Director of Nursing (DON) | Interviewed and indicated missing narcotic medications and count sheet issues |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 1
Date: May 29, 2025
Visit Reason
This visit was conducted for the investigation of complaint IN00459224 regarding allegations of misappropriation of residents' narcotic medications.
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.
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.
Deficiencies (1)
Failed to ensure residents were free from misappropriation of narcotic medications, resulting in missing medications and missed doses for Resident D and Resident G.
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
Date: 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
Date: 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.
Deficiencies (1)
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.
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
Date: 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.
Deficiencies (7)
Failed to ensure emergency preparedness policies included updated arrangements with other LTC facilities to receive residents in case of operational limitations.
Failed to provide documentation for monthly 30-second and annual 90-minute testing of battery powered emergency lighting.
Failed to provide documentation of semiannual inspection of kitchen exhaust system as required by NFPA 96.
Failed to maintain semiannual visual inspections of fire alarm system devices such as smoke detectors and heat detectors.
Failed to maintain ceiling in laundry room to allow sprinkler heads to function properly due to a 4x3 inch hole.
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.
Failed to conduct required maintenance and maintain documentation for patient care related electrical equipment testing.
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
Complaint Investigation
Deficiencies: 11
Date: Jan 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to multiple concerns including failure to provide timely transfer and discharge notices, bed hold notices, inadequate respiratory care, fall prevention, medication administration, infection control practices, and environmental safety.
Complaint Details
The complaint investigation included allegations of failure to provide transfer/discharge and bed hold notices, inadequate respiratory care, fall prevention deficiencies, medication administration errors, infection control lapses, lack of qualified infection preventionist, and environmental safety concerns.
Findings
The facility failed to provide timely transfer/discharge and bed hold notices for residents hospitalized, failed to provide adequate respiratory care including oxygen equipment maintenance, failed to update fall assessments and notify families, failed to administer ordered medications, failed to provide appropriate dementia care, failed to secure narcotics properly, failed to follow infection control practices, lacked a qualified infection preventionist, and had multiple environmental deficiencies including unsanitary conditions and poor maintenance.
Deficiencies (11)
F 0623: The facility failed to provide timely notification of transfer or discharge to residents or representatives for 3 residents reviewed for hospitalizations.
F 0625: The facility failed to notify residents or representatives in writing how long the nursing home would hold the resident's bed during hospital transfers for 3 residents.
F 0689: The facility failed to provide adequate supervision and timely fall assessments for 2 residents, and failed to notify family of falls.
F 0695: The facility failed to provide safe and appropriate respiratory care for 3 residents; oxygen tubing was not changed weekly, concentrator filters were dirty, and portable oxygen tanks were not checked timely.
F 0726: The facility failed to ensure competent nurse staffing for respiratory care and wound care; an expectorant was not administered and a wound dressing was applied without physician order for 2 residents.
F 0732: The facility failed to post nurse staffing sheets daily with accurate and complete information for 6 days reviewed.
F 0744: The facility failed to provide person-centered dementia care and meaningful engagement for 2 residents with dementia.
F 0761: The facility failed to ensure proper storage of medications; narcotic boxes in medication carts were not double locked.
F 0880: The facility failed to implement infection prevention and control practices; gloves were not changed and hand hygiene was not performed during incontinence care and medication administration.
F 0882: The facility failed to designate a qualified infection preventionist; the interim infection preventionist lacked infection control certification.
F 0921: The facility failed to maintain a safe, clean, and comfortable environment; multiple environmental deficiencies were observed including unsanitary shower rooms, soiled toilets, missing paint and baseboards, dusty vents and fans, and improper refrigerator temperature logs.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 4
Days: 6
Temperature: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 9 | Licensed Practical Nurse | Named in findings related to missing transfer/discharge paperwork, bed hold paperwork, respiratory care, and dementia care observations |
| Registered Nurse 3 | Registered Nurse | Named in findings related to respiratory care, medication administration, and wound care |
| Certified Nurse Aide 37 | Certified Nurse Aide | Named in infection control deficiencies during incontinence care |
| Certified Nurse Aide 41 | Certified Nurse Aide | Named in infection control deficiencies during incontinence care |
| Assistant Director of Nursing | Assistant Director of Nursing | Named as interim Infection Preventionist lacking certification |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in environmental deficiencies related to cleaning and refrigerator temperature logs |
| Maintenance Supervisor | Maintenance Supervisor | Named in environmental deficiencies and cleaning observations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to provide safe and appropriate respiratory care for residents.
Complaint Details
This citation relates to Complaint IN00450791.
Findings
The facility failed to ensure necessary respiratory care and services were provided according to professional standards for 3 residents. Issues included oxygen tubing not being changed weekly, portable oxygen tanks not being checked, and oxygen concentrator machine filters not being cleaned.
Deficiencies (1)
F 0695: The facility failed to provide safe and appropriate respiratory care by not changing oxygen tubing weekly, not cleaning oxygen concentrator filters, and not checking portable oxygen tanks as ordered for three residents.
Report Facts
Residents affected: 3
Oxygen tubing change frequency: 1
Oxygen concentrator cleaning frequency: 1
Oxygen flow rates: 2
Oxygen flow rates: 4
Oxygen flow rates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 9 | Indicated responsibility for changing oxygen tubing weekly on Sunday nights | |
| Registered Nurse (RN) 3 | Indicated oxygen tubing was changed weekly and portable oxygen tanks were checked about 2 hours after being changed | |
| Certified Nurse Aide (CNA) 37 | Replaced the portable oxygen tank with a new one and attached the nasal cannula | |
| Maintenance Supervisor | Observed soiled oxygen concentrator machine filter and took it to Housekeeping Supervisor for cleaning | |
| Housekeeping Supervisor | Responsible for cleaning oxygen concentrator machine filters |
Inspection Report
Recertification
Census: 50
Capacity: 50
Deficiencies: 11
Date: Jan 14, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Nursing Home Complaint IN00450791.
Complaint Details
Complaint IN00450791 was investigated, with federal/state deficiencies related to the allegations cited at F695.
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.
Deficiencies (11)
Failed to ensure notice of transfer or discharge was given to residents or representatives for 3 of 3 residents reviewed for hospitalizations.
Failed to ensure bed hold policy notification was given to residents or representatives for 3 of 3 residents reviewed for hospitalizations.
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.
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.
Failed to ensure competent nurse staffing; medication not administered, wound dressing initiated without order, bandage left on resident for six days.
Failed to ensure posted nurse staffing sheets were posted and contained correct information daily for 6 of 6 days reviewed.
Failed to ensure person-centered dementia treatment and services for 2 of 4 residents reviewed for dementia care.
Failed to ensure proper storage of medications; narcotic boxes not double locked in 2 of 3 medication carts.
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.
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.
Failed to ensure a qualified Infection Preventionist worked at least part-time; interim IP lacked infection control certification.
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
Date: 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
Date: 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
Date: 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
Date: 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.
Deficiencies (4)
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.
Failed to conduct quarterly fire drills on the second shift for 1 of 4 quarters in 2023.
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.
Failed to ensure the emergency generator was allowed a 5 minute cool down period after load testing.
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
Deficiencies: 2
Date: Dec 14, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care related to respiratory care and food service temperature in the facility.
Findings
The facility failed to provide respiratory care consistent with physician orders for one resident, including failure to clean the oxygen concentrator and tubing. Additionally, the facility served cold food that was supposed to be hot for one lunch tray sampled on two halls.
Deficiencies (2)
F 0695: The facility failed to provide safe and appropriate respiratory care for a resident. Oxygen was not given as ordered and the oxygen concentrator and filter were dusty and not cleaned.
F 0804: The facility failed to ensure food was served at a safe and appetizing temperature. Hot food was served cold on one lunch tray sampled on two halls.
Report Facts
Oxygen flow rate: 2
Oxygen flow rate: 3
Food temperature: 102.6
Expected food temperature: 160
Inspection Report
Annual Inspection
Census: 51
Capacity: 51
Deficiencies: 3
Date: 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.
Complaint Details
Complaint IN00415576 was investigated and no deficiencies related to the allegations were cited.
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.
Deficiencies (3)
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).
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).
Failed to prepare or submit an Alzheimer's/Dementia Special Care Unit disclosure form as required by state regulations.
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
Date: 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.
Complaint Details
This visit was related to complaints IN00409392 and IN00401358, both of which were corrected.
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.
Report Facts
Census SNF/NF: 49
Total Capacity: 49
Census Payor Type Medicaid: 39
Census Payor Type Other: 10
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 31, 2023
Visit Reason
The inspection was conducted in response to complaint allegations IN00409392 and IN00401358 regarding the facility's failure to ensure resident safety and proper fall protocol implementation.
Complaint Details
This Federal tag relates to complaint allegations IN00409392 and IN00401358. The complaint was substantiated as the facility failed to follow fall protocols and properly document and communicate falls involving Resident B.
Findings
The facility failed to ensure a resident was free from accidents, specifically failing to implement fall protocols after a resident suffered a hip fracture and a subsequent fall. Documentation and communication regarding the falls were incomplete, and staff did not follow required procedures for fall assessments and notifications.
Deficiencies (1)
F 0689: The facility failed to ensure a resident was free from accidents and did not implement the fall protocol after a resident suffered a left hip fracture and another fall the following morning. Documentation of the falls, assessments, incident reports, and notifications to family and physician were incomplete or missing.
Report Facts
Residents reviewed for falls: 3
Date of fall resulting in hip fracture: May 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Assisted Resident B on 5/24/23 and reported falls during interviews | |
| LPN 6 | Licensed Practical Nurse | Resident B's nurse on day shift 5/24/23 who completed fall incident report and transferred resident to hospital |
| DON | Director of Nursing | Provided facility policy and described fall incident and deficient practices |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failure to ensure a resident was free of accident hazards and to provide adequate supervision and assistance devices to prevent falls.
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
Date: Jan 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399792.
Complaint Details
Complaint IN00399792 was substantiated but no deficiencies related to the allegations were cited.
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.
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
Date: Oct 25, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00373765.
Complaint Details
Complaint IN00373765 was substantiated; however, no deficiencies related to the allegations were cited.
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.
Report Facts
Census Bed Type: 52
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 8
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 28, 2021
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements at the Lodge of the Wabash nursing home.
Findings
The facility was found deficient in implementing a baseline care plan for pressure ulcers, posting accurate daily nurse staffing information, maintaining medication error rates below 5%, and enforcing proper infection prevention and control measures including appropriate use of personal protective equipment.
Deficiencies (4)
F 0655: The facility failed to implement a Baseline Care Plan for person-centered care related to pressure ulcers for 1 of 1 residents reviewed. The facility did not assess or document the pressure ulcer area upon admission.
F 0732: The facility failed to post daily nurse staffing information correctly for 8 of 8 days during the survey period, with staffing sheets not reflecting actual hours worked.
F 0759: The facility failed to maintain medication error rates below 5%, with a 12% error rate observed in medication administration for 3 of 7 residents observed.
F 0880: The facility failed to implement adequate infection prevention and control measures, including employees wearing unapproved eye protection and failure to follow PPE protocols during aerosol generating procedures.
Report Facts
Medication error rate: 12
Days with incorrect staffing posting: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Observed preparing and administering insulin without priming the insulin pen | |
| LPN 1 | Observed preparing insulin with medication errors and wearing unapproved eye protection | |
| CNA 3 | Observed wearing unapproved eye protection and providing care to Resident 23 | |
| CNA 5 | Observed wearing unapproved eye protection | |
| DON | Director of Nursing | Provided interviews and facility policies related to deficiencies |
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