Inspection Reports for
WoodBridge Health Campus
602 Woodbridge Ave, Logansport, IN 46947, LOGANSPORT, IN, 46947
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
91% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
The visit was conducted to investigate Complaint IN00461127 at Woodbridge Health Campus.
Complaint Details
Complaint IN00461127 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 86
Census Payor Type Total: 65
Inspection Report
Life Safety
Census: 64
Capacity: 69
Deficiencies: 1
Date: Jun 17, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found not in compliance with requirements for participation in Medicare/Medicaid related to Life Safety from Fire and NFPA 101 standards. Specifically, the facility failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Deficiencies (1)
K 0921 Electrical Equipment - Testing and Maintenance: The facility failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE), including electric beds, nebulizers, oxygen concentrators, and air pumps. The Director of Plant Operations had started testing but had not completed or documented all PCREE testing as of the survey date.
Report Facts
Certified beds: 69
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Snay | Executive Director | Signed the report |
| Director of Plant Operations | Interviewed regarding PCREE testing and maintenance | |
| Senior Director of Plant Operations | Present during record review and facility tour |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted.
Findings
Woodbridge Health Campus was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Recertification
Census: 63
Capacity: 86
Deficiencies: 5
Date: Jun 3, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and the Investigation of Complaint IN00454866.
Complaint Details
Complaint IN00454866 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found to have deficiencies related to advanced directives, PASARR coordination, quality of care regarding daily weights, medication errors, and pharmaceutical services. No deficiencies were related to the complaint investigated. The facility submitted plans of correction for all cited deficiencies.
Deficiencies (5)
483.10(c)(6)(8)(g)(12)(i)-(v) The facility failed to ensure a resident's advanced directives were updated for 1 of 1 resident reviewed. The code status order was not updated to reflect a signed DNR form.
483.20(e)(1)(2) The facility failed to ensure a PASARR was completed when a resident received a new mental health diagnosis and was prescribed an antipsychotic medication for 1 of 1 resident reviewed.
483.25 The facility failed to ensure daily weights were obtained as ordered and the physician was notified of weight changes for 2 of 2 residents reviewed for quality of care.
483.45(f)(2) The facility failed to ensure medications were prescribed as ordered to prevent significant medication errors for 1 of 1 resident reviewed. A medication order was not transcribed into the MAR upon admission.
410 IAC 16.2-5-6(a) The facility failed to ensure a resident's medication was secured in a locked container for 1 of 5 residents who self-administered medication. The resident's room door was unlocked and medications were stored unsecured.
Report Facts
Census Bed Type Total: 86
Census Payor Type Total: 63
Deficiencies cited: 5
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey.
Findings
Woodbridge Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 77
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
The visit was conducted to investigate Complaint IN00447648 at Woodbridge Health Campus.
Complaint Details
Complaint IN00447648 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 77
Census Payor Type Total: 56
Census by Bed Type: 22
Census by Bed Type: 34
Census by Bed Type: 21
Census by Payor Type: 17
Census by Payor Type: 26
Census by Payor Type: 13
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00439178 and IN00442809 at Woodbridge Health Campus.
Complaint Details
Complaint IN00439178 and IN00442809 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00439178 and IN00442809 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 79
Census Bed Type SNF/NF: 33
Census Bed Type SNF: 27
Census Bed Type Residential: 19
Census Payor Type Medicare: 17
Census Payor Type Medicaid: 32
Census Payor Type Other: 11
Census Payor Type Total: 60
Inspection Report
Re-Inspection
Census: 56
Capacity: 69
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 05/20/24 by the Indiana Department of Health.
Findings
At this PSR survey, Woodbridge Health Campus was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73, and with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19.
Report Facts
Certified beds: 69
Resident census: 56
Inspection Report
Renewal
Deficiencies: 0
Date: May 28, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure survey.
Findings
Woodbridge Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for Recertification and State Licensure.
Inspection Report
Routine
Census: 61
Capacity: 69
Deficiencies: 8
Date: May 20, 2024
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification survey conducted by the Indiana Department of Health.
Findings
The facility was found substantially compliant with Emergency Preparedness Requirements but had deficiencies in annual review and update of emergency preparedness plans, policies, communication plans, and training/testing. Life Safety Code deficiencies included missed quarterly fire drills on some shifts, lack of annual testing of non-hospital grade electrical receptacles, a malfunctioning emergency generator annunciator panel, and a non-functioning ventilation fan in an oxygen storage room.
Deficiencies (8)
42 CFR 483.73(a): Facility failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually. The last documented update was 01/03/2023.
42 CFR 483.73(b): Facility failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually.
42 CFR 483.73(c): Facility failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually.
42 CFR 483.73(d): Facility failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually.
NFPA 101, 19.7.1.6: Facility failed to conduct quarterly fire drills for 2 of 4 quarters on required shifts.
NFPA 99, 6.3.4.1.3: Facility failed to ensure all non-hospital-grade electrical receptacles at resident room locations were tested at least annually.
NFPA 99, 6.4.1.1.17: Facility failed to ensure emergency generator annunciator panel was in proper operating condition; a 'Bat Chrg AC Fail' light was illuminated.
NFPA 99, 11.5.2.3.1: Facility failed to ensure mechanical ventilation was working in one of two oxygen storage rooms used for oxygen transfilling.
Report Facts
Certified beds: 69
Census: 61
Fire drill quarters missed: 2
Resident rooms receptacles: 6
Residents potentially affected by ventilation issue: 14
Staff potentially affected by ventilation issue: 6
Visitors potentially affected by ventilation issue: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Nieves | Executive Director | Named in plan of correction and education related to emergency preparedness and fire drills |
| Director of Plant Operations | Named in multiple findings and corrective actions related to emergency preparedness, fire drills, electrical receptacle testing, generator annunciator, and oxygen room ventilation | |
| Facilities Maintenance Support Manager | Interviewed regarding fire drills, electrical receptacle testing, generator annunciator, and oxygen room ventilation |
Inspection Report
Recertification
Census: 52
Deficiencies: 2
Date: Apr 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and investigation of Complaint IN00429159. The visit included a Residential State Licensure survey.
Complaint Details
Complaint IN00429159 was investigated with no deficiencies related to the allegations cited.
Findings
The facility failed to ensure food was handled to maintain food safety related to discarding and thawing. Several food items were found past their use-by dates or improperly labeled, posing a risk to all residents served by the kitchen.
Deficiencies (2)
F-812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to ensure food was handled to maintain food safety related to discarding and thawing. Multiple food items were past their use-by dates or improperly labeled, including poultry and turkey in the walk-in cooler.
R-273 Food and Nutritional Services - Deficiency: All food preparation and serving areas were not maintained in accordance with state and local sanitation and safe food handling standards. The facility failed to ensure food was handled to maintain food safety related to discarding and thawing.
Report Facts
Residents served: 52
Residents served: 20
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00425685 completed on January 18, 2024.
Findings
Woodbridge Health Campus 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 to the Investigation of Complaint IN00425685.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Jan 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425685 regarding allegations of unnecessary medication use.
Complaint Details
Complaint IN00425685 was substantiated with federal and state deficiencies cited related to unnecessary medication use.
Findings
The facility failed to ensure nonpharmacological interventions were implemented prior to administering a duplicate antianxiety medication, failed to document potential medication side effects, and lacked clinical rationale for continued use of the duplicate medication for one resident.
Deficiencies (1)
483.45(d)(1)-(6) Drug Regimen is Free from Unnecessary Drugs. The facility failed to ensure nonpharmacological interventions were attempted before administering duplicate antianxiety medications, did not document potential side effects, and lacked clinical rationale for continued use for one resident.
Report Facts
Resident census: 62
SNF/NF beds: 33
SNF beds: 29
Medicare residents: 17
Medicaid residents: 31
Other payor residents: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Nieves | Executive Director | Signed the report and involved in interviews |
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00401863 and IN00402369 completed on May 15, 2023.
Complaint Details
This visit was related to complaints IN00401863 and IN00402369. Both complaints were corrected as of this visit.
Findings
Woodbridge Health Campus 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 IN00401863 and IN00402369.
Report Facts
Census Bed Type Total: 67
Census Payor Type Total: 67
Census SNF/NF: 34
Census SNF: 33
Census Medicare: 14
Census Medicaid: 32
Census Other Payor: 21
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411572.
Complaint Details
Complaint IN00411572 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 90
Census Payor Type Total: 65
SNF Beds: 31
SNF/NF Beds: 34
Residential Beds: 25
Medicare Residents: 13
Medicaid Residents: 33
Other Payor Residents: 19
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Jun 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409694.
Complaint Details
Complaint IN00409694 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 89
Census Payor Type Total: 64
SNF/NF Beds: 34
SNF Beds: 30
Residential Beds: 25
Medicare Residents: 14
Medicaid Residents: 33
Other Payor Residents: 17
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Date: May 15, 2023
Visit Reason
Investigation of Complaints IN00401394, IN00401863, and IN00402369 related to resident care and accident prevention.
Complaint Details
Complaint IN00401394 found no deficiencies related to allegations. Complaints IN00401863 and IN00402369 resulted in federal/state deficiencies cited at F689 related to failure to follow care plans and post-fall interventions.
Findings
The facility failed to ensure staff followed resident care plans for transfers, resulting in injury to Resident B during a two-person manual assist transfer and failure to implement post-fall interventions for Resident G, who sustained a head laceration and skin tears.
Deficiencies (1)
483.25(d)(1)(2) The facility failed to ensure staff followed a resident's plan of care for transfers, resulting in a nondisplaced medial tibial plateau fracture to Resident B during a two-person manual assist transfer without a gait belt. The facility also failed to implement post-fall interventions for Resident G, who sustained a head laceration and skin tears prior to interventions being put in place.
Report Facts
Census bed type total: 87
SNF beds: 18
SNF/NF beds: 46
Residential beds: 23
Medicare census: 18
Medicaid census: 26
Other payor census: 43
Inspection Report
Re-Inspection
Census: 60
Capacity: 69
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
This was a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted 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 National Fire Protection Association (NFPA) 101 Life Safety Code. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Life Safety
Census: 61
Capacity: 69
Deficiencies: 1
Date: Feb 13, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the facility was found not in compliance with Life Safety Code requirements due to failure to ensure one ceiling barrier was properly enclosed to be smoke tight.
Deficiencies (1)
LSC 19.3.1 requires vertical openings to be enclosed with at least a 1-hour fire resistance rating. The facility failed to ensure one ceiling barrier was smoke tight due to unsealed conduits with annular space around data cables.
Report Facts
Certified beds: 69
Resident census: 61
Employees potentially affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Nieves | Executive Director | Signed report and involved in exit conference |
| Director of Plant Operations | Director of Plant Operations | Acknowledged deficient smoke barrier and involved in observations |
Inspection Report
Annual Inspection
Census: 24
Capacity: 88
Deficiencies: 5
Date: Jan 26, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over January 18-26, 2023.
Findings
The facility was found to have multiple deficiencies related to coordination of PASARR assessments, quality of care including failure to assess edema and notify physician of significant weight gain, drug regimen review failures including inappropriate psychotropic medication use and failure to follow antibiotic orders. The facility was found in compliance with State Residential Licensure requirements.
Deficiencies (5)
483.20(e)(1)(2) Coordination of PASARR and Assessments. The facility failed to complete a new PASARR for a resident prescribed antipsychotic medication (Resident 42).
483.25 Quality of Care. The facility failed to assess for edema and notify the physician of significant weight gain for 1 of 6 residents reviewed (Resident 155).
483.45(c)(1)(2)(4)(5) Drug Regimen Review. The facility failed to ensure the consultant pharmacist made recommendations for irregularities in diagnoses and medications prescribed for 1 of 2 residents reviewed for unnecessary psychotropic medications (Resident 42).
483.45(d)(1)-(6) Drug Regimen is Free from Unnecessary Drugs. The facility failed to ensure a physician's order for antibiotics was followed for 1 of 5 residents reviewed (Resident 19).
483.45(c)(3)(e)(1)-(5) Free from Unnecessary Psychotropic Meds/PRN Use. The facility failed to ensure a resident with dementia had an appropriate diagnosis for antipsychotic and mood stabilizing medications and to ensure lab parameters were followed for 1 of 2 residents reviewed (Resident 42).
Report Facts
Survey dates: 7
Census Bed Type Total: 88
Residential Census: 24
Weight gain percentage: 14.16
Lithium level: 1.8
Antibiotic doses: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Nieves | Executive Director | Signed the report as facility representative. |
| Social Services Director | Interviewed regarding PASARR completion and medication reviews. | |
| Consultant Pharmacist | Interviewed regarding medication reviews and psychotropic medication appropriateness. | |
| Director of Nursing | Interviewed regarding weight gain management and notification. | |
| Clinical Support Nurse | Provided policies and interviewed regarding antibiotic stewardship and medication reviews. | |
| RN 3 | Observed wound care and edema on Resident 155. | |
| RN 4 | Interviewed regarding Resident 155's edema. | |
| Nurse Practitioner | Documented clinical notes on Resident 42's medication effects and lab results. |
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 26, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on January 26, 2023.
Findings
Woodbridge Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
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