Lodge of the Wabash

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified Infection Preventionist (IP) working at least part-time at that facility. The Director of Nursing (DON) acted as the IP, but lacked documentation of hours worked as the IP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the Medical Doctor/Nurse Practitioner (MD/NP) about significant changes in a resident's physical and functional ability for 1 of 1 resident reviewed for positioning. (Resident 26)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was discharged with sufficient preparation for 1 of 3 closed records reviewed. A discharged resident failed to receive appropriate paperwork and assessments prior to being sent to the hospital. (Resident 44)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with a decline in positioning was offered an evaluation for adaptive devices or equipment to help her maintain the highest practicable physical and functional well-being for 1 of 1 resident reviewed for positioning. A resident with kyphosis was observed leaning so far to the right seated in her wheelchair that her right axilla (arm pit) rested on the arm rest of the wheelchair and her head was down towards her knees. (Resident 26)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage of medications in 1 of 1 medication storage room. The temperature log for the refrigerator and room temperature lacked several readings. (Medication Storage Room)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate information was documented in the clinical record for 1 of 4 residents reviewed for nutrition. Meal intake documentation was missing and meal and snack consumption was recorded in the clinical record before the resident was served. (Resident 26)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper hand hygiene to help prevent the development and transmission of communicable diseases and infections for 2 of 2 observations of incontinence care. Staff washed their hands with an 8, 10, 15 and 12 second lather. (Resident 26, Resident 22)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow antibiotic use protocol for 1 of 1 resident reviewed for urinary tract infection. An antibiotic was ordered and given prior to culture results that was resistant to the bacteria. (Resident 22)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the past state survey results were readily available to visitors, residents, and other individuals without them having to ask to review them for 2 of 2 days reviewed for the survey period.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation for 2 of 3 residents reviewed pharmaceutical services. Resident's narcotic medications went missing after being delivered from the pharmacy which caused residents to miss physician ordered routine medications. (Resident D, Resident G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 residents during observation of incontinence care and 7 of 16 observations of medication administration. Gloves were not changed and hand hygiene was not performed between dirty and clean tasks during peri care, hand hygiene was not performed prior to administering medications, and staff performed a 2 second hand lather. (Resident B, Resident F, Resident 37, Resident 12, Resident 14, Resident 39, Resident 46, Resident 2, Resident 41).

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified Infection Preventionist (IP) worked at least part-time at that facility, and the interim IP lacked an infection control certification.

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary and home-like environment for 3 of 3 halls, 1 of 1 shower rooms reviewed for environment, and 19 of 19 resident personal refrigerator temperature logs reviewed. Personal items and linens were not labeled and uncovered, vent fans were caked with dust, toilets were soiled, paint was missing, baseboards were falling off or missing, and a toilet seat riser was uncovered on the floor under the sink in the shower rooms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 3 of 3 residents reviewed for hospitalizations. The transfer discharge form was not completed. (Resident 27, Resident 37, Resident 13)

Inspectors wroteBased on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 3 of 3 residents reviewed for hospitalizations. The bed hold form was not completed. (Resident 27, Resident 37, Resident 13)

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision and prevent falls for 2 of 6 residents reviewed for accidents. Fall assessments and care plans were not updated in a timely manner and family was not notified a fall. (Resident 44, Resident 33)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice for 3 of 3 residents reviewed for respiratory care. Oxygen tubing was not changed, portable oxygen tanks were not checked, and oxygen concentrator machine filters were not cleaned. (Resident C, Resident B, Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure competent nurse staffing necessary to provide services to meet resident rights and well-being for 1 of 3 residents reviewed for respiratory care and 1 random observation. A resident's order for an expectorant was not administered, a wound dressing was initiated without an order or notification to the physician, and a bandage was left on a resident for six days. (Resident 43, Resident 46)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure person-centered dementia treatment and services were provided for 2 of 4 residents reviewed for dementia care. (Resident 46, Resident 47)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage of medications in 2 of 3 medication carts. Narcotic boxes were not double locked in the medication carts. (200 Hall medication cart, 400 Hall medication cart)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure posted nurse staffing sheets were posted and contained the correct information daily for 6 of 6 days reviewed. (January 2, 3, 8, 9, 13, 14, 2025)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen. A resident's oxygen was not given as ordered and the oxygen concentrator and filter were not cleaned. (Resident 12)

Inspectors wroteBased on observation and interview the facility failed to provide hot food for 1 of 1 lunch trays sampled on 1 of 2 halls. Food that was supposed to be served hot was served cold. (300 hall and 400 hall)