Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lodge Of The Wabash during CMS and state inspections, most recent first.
A facility failed to ensure a qualified IP was working at least part-time. The DON served as the IP, DON, and MDS nurse, but had no documentation of hours spent on IP duties. Regional Support also stated the backup IP lacked certification, and the facility’s job description required a part-time clinical staff member with specialized infection prevention and control training.
A resident with bipolar disorder, anxiety, and dementia had a significant decline from walking independently to using a manual wheelchair with partial to moderate assist for transfers, but the record lacked documentation that the MD/NP was notified. Staff observed worsening slouching and right-sided leaning in the wheelchair, and the resident was seen striking chairs, a wall, and a handrail while propelling herself.
Incomplete Transfer and Discharge Documentation: A resident with DM and moderate cognitive impairment was sent to the hospital without progress notes, discharge assessments, respiratory assessments, or a completed transfer/discharge and bed-hold form in the chart. The CNM and Regional Support confirmed the resident had no assessments or documentation leading up to the emergent transfer, and the facility policy required transfer/discharge documentation to be included in the medical record.
A resident with bipolar disorder, anxiety, and dementia had a marked decline from walking independently to using a manual wheelchair with staff assistance for transfers, while staff documented worsening posture, weakness, and difficulty holding her head up for meds and meals. She was repeatedly observed slouched far to one side in her wheelchair with her arm hanging off the armrest and her head down toward her knees, and at one point she struck chairs, a wall, and a handrail while propelling herself. Staff said no positioning devices were being used, therapy had discharged her after meeting goals, and no further evaluation for adaptive equipment or positioning had been initiated.
Missing Medication Storage Temperature Logs: The facility failed to ensure proper medication storage in the medication room when the refrigerator and ambient room temperature log had multiple missing shift readings. RN stated temps should be checked and recorded every shift, and the facility policy required nursing staff to document refrigerator and room temperatures each shift.
Inaccurate nutrition documentation was found for a resident with bipolar disorder, anxiety, and dementia who was receiving assistance with eating and had significant weight loss. The meal and snack log had multiple missing entries and several entries were charted before the resident was served, despite the care plan requiring food intake to be monitored and documented and the facility’s policy stating entries should not be made in advance.
Improper Hand Hygiene During Incontinence Care: Staff did not perform hand hygiene for the full required duration during incontinence care for two residents. A QMA and CNAs were observed toileting residents, washing hands with lathers lasting only 8, 10, 12, and 15 seconds before donning gloves and assisting with transfers. The DON stated hand washing should involve 30-40 seconds of lathering, and the facility policy required a 40-60 second hand hygiene procedure.
Antibiotic Use Protocol Not Followed for UTI: A resident with dementia and depression, who was dependent for toileting and frequently incontinent, was treated for a UTI with Keflex based on cloudy, amber urine before culture results returned. The urine culture later showed the bacteria was not sensitive to Keflex, and the MAR showed the antibiotic was given until the culture results were received and Bactrim was ordered.
Survey Results Not Readily Available: The facility failed to keep past state survey results readily available for residents, visitors, and others without asking to review them. Residents reported a sign at the nurse's station directing people to a binder, but the slot contained only an emergency preparedness binder on repeated observations. The Administrator later found the survey history binder in the business office, and Regional Support stated there was no policy for keeping the survey results readily available.
Two residents with severe cognitive impairment and chronic pain conditions missed multiple doses of prescribed narcotic pain medications after full sheets of these medications went missing from the medication cart. Facility records showed discrepancies between the number of doses delivered and those accounted for, and required shift-to-shift narcotic counts were not consistently performed. As a result, the residents received alternative pain medications while the facility worked to replace the missing narcotics.
The facility failed to follow infection control practices during incontinence care and medication administration. CNAs did not change gloves or perform hand hygiene between tasks for two residents, and a nurse did not adequately sanitize hands during medication passes for several residents. These actions were contrary to the facility's policies on hand hygiene and infection control.
The facility did not have a qualified Infection Preventionist (IP) working at least part-time. The DON, who was the designated IP, was on leave, and the interim IP, the ADON, lacked infection control certification. The facility lacked documentation on hours dedicated to infection prevention, and the DON's schedule only allocated Thursdays for infection control. The IP role required specialized training beyond the initial professional degree, which the interim IP did not have.
The facility failed to maintain a sanitary and home-like environment, with issues such as dusty and broken blinds, uncovered personal items, soiled toilets, and missing paint observed in multiple areas. Refrigerator temperature logs were inconsistently maintained, and staff interviews revealed a lack of clear procedures for cleaning and maintenance tasks. The facility lacked specific policies for maintaining a homelike environment and checking refrigerator temperatures, contributing to the deficiencies.
The facility failed to provide required transfer or discharge notices to residents or their representatives for three residents who were hospitalized. Clinical records for these residents lacked the necessary documentation, and staff interviews confirmed the absence of completed paperwork. The facility's policy mandates that such notices be completed and included in the resident's clinical record, but this was not adhered to.
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, as evidenced by the lack of completed bed hold paperwork for three residents. A resident with moderate cognitive impairment and multiple health issues was hospitalized without the necessary documentation. Similarly, another resident with severe cognitive impairment and a history of multiple hospitalizations also lacked bed hold paperwork. A third resident with several hospitalizations for various health issues did not have documented bed hold notices, despite the facility's policy requiring written notice at the time of transfer.
The facility failed to provide adequate supervision and prevent falls for two residents with severe cognitive impairments. Delays in completing fall assessments and updating care plans were noted, with some assessments completed weeks after the falls. Additionally, family notifications were not made in a timely manner, contrary to the facility's protocol.
The facility failed to provide necessary respiratory care for three residents, including not changing oxygen tubing weekly, not cleaning oxygen concentrator filters, and not ensuring portable oxygen tanks were adequately filled. A resident was found with outdated tubing and soiled filters, another with dusty concentrator filters, and a third with an empty portable oxygen tank. These deficiencies were observed despite physician orders and care plans requiring regular maintenance and checks.
The facility failed to ensure competent nurse staffing, resulting in deficiencies in medication administration and wound care. A resident did not receive an ordered expectorant due to unavailability and lack of notification to the DON. Another resident had a bandage left on for six days and a skin tear treated without a physician's order. Facility policies on medication, treatment accuracy, and skin care management were not followed.
The facility failed to provide person-centered dementia care for two residents, who were often left without engagement or meaningful activities. Despite care plans suggesting interaction and participation in activities, staff did not adhere to these plans, leaving the residents unstimulated and unsupported. Observations showed residents sitting in wheelchairs or recliners with minimal staff interaction, highlighting a deficiency in the facility's dementia care approach.
The facility failed to secure narcotic boxes in two medication carts, as observed on multiple occasions. A narcotic box in the 200 Hall cart and another in the 400 Hall cart were found unlocked. An RN confirmed that narcotic boxes should be locked when not in use, in accordance with the facility's policy requiring double-locking of Schedule 2 controlled substances.
The facility failed to accurately post nurse staffing sheets for six consecutive days. Observations showed that the sheets lacked detailed information about specific hours worked by staff, with some shifts not fully documented. The ADON confirmed that the shift nurse was responsible for filling out the sheets, and the Clinical and Quality Consultant noted the absence of a specific policy, relying instead on federal guidelines.
Qualified Infection Preventionist Not Documented
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time at the facility. During interview, Regional Support stated the DON was the current IP and the Clinical Nurse Manager was the backup IP, but the backup lacked certification. The DON stated she was acting as the current IP, DON, and MDS nurse, and she did not have documentation of the hours she spent performing IP duties. The Administrator provided an Infection Prevention and Control Officer job description revised 2/24, which stated the role required at least a part-time clinical staff member responsible for supporting the facility’s systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, and that the person would have specialized training and education in infection prevention and control beyond their initial professional degree.
Failure to Notify MD/NP of Resident’s Declining Physical and Functional Status
Penalty
Summary
The facility failed to notify the MD/NP about significant changes in Resident 26’s physical and functional ability. The resident had diagnoses including bipolar disorder, anxiety, and dementia, and the record showed a change from the most recent quarterly MDS, which indicated she did not use a walker or wheelchair, was independent for transfers, and could walk 150 feet independently, to the most recent Significant Change MDS, which indicated she used a manual wheelchair, needed partial to moderate assistance for transfers, and had received PT and OT in the prior seven days. On observation, Resident 26 was seen propelling herself in a wheelchair while leaning far to the right, with her right axilla over the armrest, her arm hanging off the side, and her head down toward her knees. She ran into chairs at the nurse’s station and then struck her head into the wall and handrail in the hallway. Progress notes from 11/1/25 through 2/25/26 documented declining physical and functional abilities, but there was no documentation that the MD was notified. Staff interviews stated the resident had recently started slouching more, had been placed in a wheelchair because she could not ambulate safely, and had been declining mentally and physically, with worsening right-sided leaning over the past couple of months.
Incomplete Transfer and Discharge Documentation
Penalty
Summary
The facility failed to ensure that Resident 44 was prepared for a safe transfer/discharge when the resident was sent to the hospital. Resident 44 had diagnoses including diabetes mellitus and was admitted to the facility with an admission MDS indicating moderate cognitive impairment. The resident was discharged to the hospital, but the clinical record lacked progress notes related to the discharge, and there was no documentation of discharge assessments before or on the date of the hospitalization. The record also lacked respiratory assessments and did not contain a transfer/discharge and bed-hold form for the hospital transfer. During interviews, the Clinical Nurse Manager stated that Resident 44 had no assessments or documentation leading up to the hospitalization, and the Regional Support stated the resident was sent out emergently. The Regional Support also stated that documentation and assessments leading up to the discharge, along with a completed transfer/discharge and bed-hold form, would be expected. The facility policy provided by the Administrator stated that transfer and discharge documentation must be included in the medical record.
Failure to Address Worsening Wheelchair Positioning
Penalty
Summary
The facility failed to ensure that a resident with a decline in positioning was offered an evaluation for adaptive devices or equipment to help maintain the highest practicable physical and functional well-being. Resident 26 had diagnoses including bipolar disorder, anxiety, and dementia, and her record showed a change from being ambulatory and independent with transfers to using a manual wheelchair with partial to moderate staff assistance for transfers. The resident’s recent notes documented worsening posture, increased weakness, and a decline in activities of daily living, ambulation, and feeding, with staff noting that her posture had declined considerably and that they sometimes had to hold her head up to give medications and to eat. Observations showed the resident repeatedly seated in her wheelchair leaning so far to the right that her right axilla rested on the wheelchair armrest, her arm hung off the side, and she was slouched forward with her head toward her knees. She was seen in this position in the dining room, while propelling herself to the dining room, during lunch, and in the shower room before toileting. During one observation, she ran into chairs at the nurse’s station and then ran her head into the wall and handrail while moving down the hallway. During toileting, she remained slouched forward with her head toward her knees, and a QMA told her to try to sit up straight or she was going to fall off the toilet. The record showed therapy had recently worked with the resident on gait and sitting laterally in her wheelchair, but therapy discharged her after goals were met. Staff interviews indicated they were not using positioning devices and were mainly encouraging her to sit up straighter. An OTA stated nursing should notify the MD/NP so the resident could be evaluated for positioning and possible assistance, while a regional support staff member stated nothing had been tried for the worsening slouching and positioning. The administrator stated the facility did not have a positioning or maintaining highest practical well-being policy and would follow standard practice.
Missing Medication Storage Temperature Logs
Penalty
Summary
The facility failed to ensure proper storage of medications in 1 of 1 medication storage room. On 2/25/26 at 9:49 A.M., the February 2026 temperature log posted on the refrigerator in the medication storage room was observed to be missing multiple refrigerator and room temperature readings. The missing entries included refrigerator temperatures for evening and night shift on 2/10/26, refrigerator and room temperatures for evening and night shift on 2/12/26 and 2/13/26, room temperatures for day shift on 2/16/26, refrigerator and room temperatures for day, evening, and night shift on 2/18/26, refrigerator and room temperatures for evening shift on 2/19/26, refrigerator and room temperatures for night shift on 2/20/26, refrigerator and room temperatures for day shift on 2/21/26 and 2/22/26, and refrigerator temperatures for night shift on 2/23/26. During an interview on 2/25/26 at 10:00 A.M., RN 12 stated that the refrigerator and room temperatures should be checked every shift and recorded on the log. On 3/4/26 at 9:30 A.M., the Regional Support provided a Storage of Medications and Biologicals policy dated 5/21/18, which indicated that manual temperature checks should be performed per facility policy and that nursing staff were to check the medication room refrigerator and ambient room temperature each shift and record the temperatures on the log.
Inaccurate Meal and Snack Intake Documentation
Penalty
Summary
The facility failed to ensure accurate nutrition documentation in the clinical record for one resident who had diagnoses including bipolar disorder, anxiety, and dementia. The resident’s most recent Significant Change MDS, dated 1/27/26, indicated cognition could not be assessed and that staff provided partial to moderate assistance with eating. The resident’s care plan directed staff to monitor and document food intake, provide snacks between meals, and record food intake. The resident also had a documented weight loss from 135.4 lbs on 1/5/26 to 116.8 lbs on 2/23/26. Review of the meal and snack intake log from 2/1/26 to 3/2/26 showed multiple missing meals and snacks, and several entries were documented before the resident was served. Examples included missing all meals and snacks on some days, missing dinner and both snacks on multiple days, and snack or meal entries recorded at times that did not match the facility’s meal and snack schedule. The Administrator stated meals were served at 7:30 A.M., 11:30 A.M., and 5:30 P.M., and a CNA stated snacks should be offered around 2:00 P.M. and between 7:00-8:00 P.M., with refusals or 0% documented if the resident did not eat. The CNA also stated meal and snack consumption should be documented after the resident eats, not before. The facility’s documentation policy stated entries should be made as soon as possible after an event and never in advance.
Improper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure staff used proper hand hygiene during incontinence care for 2 residents. On 3/3/26 at 9:26 A.M., QMA 6 and CNA 14 were observed toileting Resident 26 in the shower room. After the resident was seated on the toilet, QMA 6 washed her hands with an 8-second lather and put on gloves, then removed Resident 26's soiled incontinence pad and discarded it in the trashcan. QMA 6 then washed her hands again with a 10-second lather before applying the gait belt and assisting Resident 26 to stand with CNA 14. On 3/2/26 at 2:02 P.M., QMA 6 and CNA 8 took Resident 22 into the shower room to void. QMA 6 washed her hands with a 15-second lather and CNA 8 washed his hands with a 12-second lather. After putting on gloves, QMA 6 placed the gait belt around Resident 22's waist, CNA 8 moved and locked the wheelchair, and both staff assisted Resident 22 to stand, walk a few steps, turn, and sit on the toilet. The DON stated hand washing should involve lathering with soap for 30-40 seconds, and the facility's hand hygiene policy stated the duration of the entire procedure is 40-60 seconds.
Antibiotic Use Protocol Not Followed for UTI
Penalty
Summary
The facility failed to follow its antibiotic use protocol for 1 of 1 resident reviewed for a urinary tract infection. The resident had diagnoses including dementia and depression, was unable to complete the BIMS because the resident was rarely or never understood, and was dependent on staff for toileting with frequent urinary incontinence. Physician orders showed Keflex 500 mg twice daily for 7 days for UTI, dated 1/7/26 and discontinued on 1/12/26, followed by Bactrim 800 mg-160 mg twice daily through 1/19/26 for UTI, dated 1/12/26 and completed on 1/19/26. A nurse's note dated 1/7/26 indicated the resident's urine was amber and cloudy, with no other symptoms documented. A urinalysis dated 1/7/26 indicated a UTI, and a urine culture resulted on 1/9/26 showing the bacteria was not sensitive to Cephalexin. The MAR showed Keflex was administered from the evening of 1/7/26 through the morning of 1/12/26 until culture results were received and Bactrim was ordered. During interview, RN 4 stated providers normally order an antibiotic for UTI based on symptoms before culture results return. The facility's Infection Prevention and Control Program policy stated antibiotics will not be utilized in residents with asymptomatic bacteriuria by following the UTI protocol.
Survey Results Not Readily Available
Penalty
Summary
The facility failed to ensure that past state survey results were readily available to visitors, residents, and other individuals without having to ask to review them for 2 of 2 days reviewed during the survey period. During the resident council meeting on 3/3/26, residents stated there was a sign on the wall at the nurse's station indicating the state survey results should be in a binder under it. However, on 3/3/26 at 7:00 A.M. and again on 3/4/26 at 9:10 A.M., the sign was observed at the nurse's station, but the slot below it contained only a blue emergency preparedness binder and not the survey results. During an interview on 3/4/26 at 9:30 A.M., the Administrator stated the sign should have been removed because the facility no longer kept the past state survey results there, and she retrieved a binder labeled survey history from the top of a filing cabinet in the business office with other binders. There was no indication that this was where the survey history binder was kept. Regional Support later stated they did not have a policy for keeping the past survey results readily available, but would follow regulations.
Failure to Safeguard Narcotic Medications Leads to Missed Pain Doses
Penalty
Summary
The facility failed to protect residents from misappropriation of their narcotic medications, resulting in two residents missing physician-ordered pain medications. For one resident with severe cognitive impairment, osteoarthritis, chronic kidney disease, and diabetes, the medication administration record showed that oxycodone was unavailable for several days, and the resident was instead given Tylenol for pain. The controlled drug record indicated that a significant number of oxycodone doses were received from the pharmacy, but the last dose was signed out several days before the medication ran out, and the delivery sheet showed more doses were delivered than were accounted for in the medication cart. Another resident, also with severe cognitive impairment and multiple serious diagnoses including malignant neoplasm, diabetes, hemiplegia, and cirrhosis, was prescribed Norco for pain. The medication administration record documented that Tylenol was given when Norco was not available. The controlled drug record and pharmacy delivery sheet indicated that more doses were delivered than were present in the medication cart, and the resident missed routine doses of their narcotic medication. Facility investigation revealed that full sheets of narcotic medications had gone missing from the medication cart, and that required shift-to-shift narcotic counts were not consistently performed or documented. Interviews with nursing staff and facility leadership confirmed that medication count sheets and narcotic medications were missing, and that the lack of consistent shift counts made it impossible to determine the exact number of missing doses. Both residents received alternative pain medication while the facility worked to obtain new orders and refills from the pharmacy. The facility's own policy required that all controlled substances be counted by two nurses at each shift change, but this procedure was not followed, contributing to the loss of medications.
Infection Control Lapses in Incontinence Care and Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care and medication administration for several residents. During incontinence care for Resident B, a CNA did not change gloves or perform hand hygiene between handling soiled and clean items. Similarly, during care for Resident F, CNAs did not sanitize their hands after removing gloves and handling various items. These lapses in protocol were observed during the transfer and cleaning of residents, where gloves were not changed, and hand hygiene was not performed as required. Additionally, during medication administration, a registered nurse did not perform adequate hand hygiene before and after administering medications to multiple residents. Observations revealed that hand lathering was performed for only 2 to 8 seconds, which is below the recommended duration. The facility's policies on hand hygiene and medication administration were not followed, as staff failed to sanitize hands before and after medication preparation and administration, contributing to the deficiency.
Inadequate Infection Preventionist Coverage
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, as required. The Director of Nursing (DON), who was designated as the IP, was on leave, and the interim IP, the Assistant Director of Nursing (ADON), lacked the necessary infection control certification. Interviews revealed that the facility did not have documentation on the hours dedicated to infection prevention, and the DON's schedule only allocated Thursdays for infection control activities. The job description for the Infection Prevention and Control Officer required specialized training and education in infection prevention and control beyond the initial professional degree, which the interim IP did not possess.
Sanitation and Maintenance Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a sanitary and home-like environment across multiple areas, including three halls, a shower room, and several resident rooms. Observations revealed numerous issues such as dusty and broken blinds, uncovered personal items and linens, soiled toilets, missing paint, and baseboards that were either falling off or missing. In the shower room, there were unlabeled personal care items, cobwebs, bugs in light covers, and a toilet seat riser left uncovered on the floor. The water temperature in the sink was also noted to be significantly low at 56.6 degrees Fahrenheit. In several resident rooms, there were issues with cleanliness and maintenance. Vents were blackened and caked with dust, paint was missing, and refrigerator temperature logs were not consistently maintained. Some rooms had strong odors, debris, and spiderwebs, while others had missing or loose fixtures such as toilet paper holders and doorknob pieces. The refrigerator temperatures were often not recorded, and when they were, they showed inconsistencies, with some logs being filled out retroactively by the Housekeeping Supervisor. Interviews with staff revealed a lack of clear procedures and responsibilities for cleaning and maintenance tasks. Housekeepers and maintenance staff were reportedly short-staffed, leading to difficulties in keeping up with cleaning and repairs. The Housekeeping Supervisor was responsible for checking refrigerator temperatures, but when absent, the task was delegated without proper documentation. The Assistant Director of Nursing and other staff indicated that personal items should be labeled and stored properly, but this was not consistently practiced. The facility lacked specific policies for maintaining a homelike environment and checking refrigerator temperatures, contributing to the deficiencies observed.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents or their representatives, as required by regulations. This deficiency was identified for three residents who were hospitalized. For Resident 27, the clinical records showed hospitalization from December 1 to December 5, 2024, but lacked the necessary transfer or discharge paperwork. Interviews with staff revealed that the paperwork was not retained, and the nurse responsible for the transfer did not keep a copy of the documentation. Similarly, Resident 37's records indicated multiple hospitalizations, but the transfer or discharge paperwork was missing. The Clinical and Quality Consultant was unable to locate the necessary documentation. For Resident 13, the records showed several hospitalizations, but there was no documentation of transfer or discharge notices being provided to the resident or their representative. The facility's policy required that such notices be completed, copied, and included in the resident's clinical record, but this was not done.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, as evidenced by the lack of completed bed hold paperwork for three residents. Resident 27, who had moderate cognitive impairment and multiple health issues, was hospitalized for sepsis and weakness, but the clinical records did not contain the necessary bed hold documentation. Interviews with facility staff revealed that the paperwork was not retained or properly managed, indicating a lapse in protocol. Similarly, Resident 37, with severe cognitive impairment and a history of multiple hospitalizations for conditions such as sepsis and heart failure, also lacked bed hold paperwork in their clinical records. The Clinical and Quality Consultant confirmed the absence of this documentation. Resident 13, who had several hospitalizations for various health issues, including stroke and end-stage renal disease, also did not have documented bed hold notices. The facility's current bed hold policy, revised in 2017, mandates written notice to be provided at the time of transfer, which was not adhered to in these cases.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide adequate supervision and prevent falls for two residents, as evidenced by the lack of timely updates to fall assessments and care plans. Resident 44, who has severe cognitive impairment and requires substantial assistance, experienced multiple falls over a period of time. The clinical records for Resident 44 showed significant delays in completing fall assessments and updating care plans, with some assessments being completed weeks after the falls occurred. Additionally, the family of Resident 44 was not notified of at least one fall, which is contrary to the facility's protocol. Similarly, Resident 33, who also has severe cognitive impairment and requires substantial assistance, experienced a fall without a subsequent fall assessment or family notification. The facility's Fall Assessment and Prevention Protocol, which mandates immediate care plan updates and family notifications, was not adhered to in these cases. The Clinical and Quality Consultant confirmed that the protocol requires fall assessments to be completed within four hours and family notifications to occur on the same shift as the fall, highlighting the facility's failure to follow its own procedures.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for three residents. Resident C was observed with oxygen tubing that had not been changed since 12/8/24, and the oxygen concentrator machine filter was soiled with dust and hair on multiple occasions. Despite physician orders and a COPD care plan requiring weekly changes and cleaning, these tasks were not completed as scheduled. Licensed Practical Nurse 9 confirmed that the night nurse was responsible for changing the tubing weekly, but this was not documented or executed as required. Resident D was also observed with dusty filters on the oxygen concentrator and oxygen tubing that was not changed as per the weekly schedule. The resident, who had diagnoses including COPD and was on hospice care, required continuous oxygen therapy. Despite physician orders for weekly maintenance, the necessary cleaning and tubing changes were not performed, as confirmed by Registered Nurse 3. Resident B was found using a portable oxygen tank that was nearly empty, with the arrow on the tank in the red area, indicating it was depleted. The resident, who had multiple diagnoses including advanced dementia and heart failure, was using oxygen at 4 liters per minute. The portable tank was not checked in a timely manner, leading to the resident being without adequate oxygen supply until the tank was replaced. RN 3 acknowledged that portable tanks were checked approximately two hours after being changed, but this was insufficient to ensure continuous oxygen supply for the resident.
Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to ensure competent nurse staffing necessary to provide services to meet resident rights and well-being, as evidenced by deficiencies in medication administration and wound care. For one resident, an expectorant medication, guaifenesin, was ordered but never administered due to unavailability. Despite the resident exhibiting symptoms such as coughing, the medication was not ordered by the Director of Nursing (DON) because the nurse failed to notify the DON of the medication's unavailability. Consequently, the medication was discontinued without being administered, as the resident's symptoms were deemed no longer present. In another case, a resident with severe cognitive impairment was found with a bandage on her wrist that had been left for six days following a blood draw. The staff, including Certified Nurse Aides (CNAs) and a Licensed Practical Nurse (LPN), were unaware of the reason for the bandage and failed to remove it in a timely manner. Additionally, a skin tear on the resident's wrist was treated without a physician's order, and the nurse did not notify the physician as required by facility protocol. The facility's policy mandates that all dressings require a physician's order and that any skin integrity issues should be documented and communicated to the physician. The facility's policies on medication and treatment accuracy, as well as skin care management, were not adhered to, leading to these deficiencies. The Clinical and Quality Consultant confirmed that the nurse should have checked for facility stock of the medication and notified the DON if unavailable. Furthermore, the facility's protocol for skin assessments and treatment orders was not followed, as evidenced by the lack of weekly skin assessments for all residents and the absence of a treatment order for the resident's skin tear.
Deficiency in Person-Centered Dementia Care
Penalty
Summary
The facility failed to provide person-centered dementia care for two residents, Resident 46 and Resident 47, as observed during multiple instances. Resident 46 was frequently seen sitting in a wheelchair or recliner, often with her eyes closed or weeping, and staff did not engage with her. Despite having a care plan that included engaging in conversation and encouraging participation in activities, staff were observed walking by without interaction. Resident 46's clinical record indicated severe cognitive impairment, and she had experienced multiple falls, yet there was a lack of meaningful engagement or stimulation provided by the staff. Resident 47 was similarly observed sitting in a wheelchair at the nurses' station or in the activity room, often fidgeting and attempting to get up without staff engagement. Although her care plan suggested activities like ball toss and sing-alongs, staff did not provide these or other forms of stimulation. The resident was left unsupervised at times, and staff interactions were minimal and ineffective in redirecting her behavior. Her clinical record also indicated severe cognitive impairment, and she required assistance with daily activities. The facility's dementia management policy emphasized the need for individualized care plans and meaningful stimulation to avoid boredom, yet these were not implemented effectively for the residents observed. The lack of engagement and appropriate activities for Residents 46 and 47 highlights a deficiency in the facility's approach to dementia care, as staff failed to adhere to the established care plans and policies designed to ensure the residents' well-being.
Improper Storage of Narcotics in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage of medications in two of three medication carts, specifically regarding the security of narcotic boxes. On two separate occasions, the narcotic box in the 200 Hall medication cart was observed to be unlocked. Similarly, the narcotic box in the 400 Hall medication cart was also found unlocked. During an interview, a registered nurse confirmed that narcotic boxes should be locked when not in use. The facility's Controlled Substances Policy, revised in April 2021, mandates that all Schedule 2 controlled substances must be stored in double-locked areas, which was not adhered to in these instances.
Inaccurate Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that the posted nurse staffing sheets were accurately completed and displayed daily for six consecutive days. Observations on various dates revealed that the staffing sheets were posted behind the nurse's desk with the correct date, but they lacked detailed information about the specific hours worked by each staff member. For instance, on multiple occasions, the sheets did not differentiate the hours worked by the staff, and in some cases, only the day shift information was filled out, with no details provided for the evening shift. This lack of differentiation in hours worked was consistent across all observed days. During an interview, the Assistant Director of Nursing (ADON) acknowledged that the shift nurse was responsible for filling out the posted nurse staffing upon arrival for their shift. The ADON indicated that the hours worked should be specified under the shift and schedule to differentiate who was working which hours. It was noted that if two staff members worked half shifts, they were counted as one staff member. Additionally, the Clinical and Quality Consultant mentioned that there was no specific policy for posted nurse staffing, but they followed federal guidelines.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 165 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vincennes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gentle Care Strategies | 1 mi | ★★★★★ | 0 | 0 |
| Bridgepointe Health Campus | 1.9 mi | ★★★★★ | 5 | 0 |
| Aperion Care Vincennes | 6.1 mi | ★★★★★ | 24 | 0 |
| The Haven Of Bridgeport | 13.2 mi | ★★★★★ | 6 | 0 |
| Oak Village | 16.3 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lodge Of The Wabash.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.