Woodbridge Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Logansport, Indiana.
- Location
- 602 Woodbridge Ave, Logansport, Indiana 46947
- CMS Provider Number
- 155724
- Inspections on file
- 25
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Woodbridge Health Campus during CMS and state inspections, most recent first.
A resident with multiple chronic conditions had a signed DNR form indicating a wish for DNR status, but the electronic medical record continued to list the resident as full code. Nursing staff and the ADON confirmed that the code status should have been updated upon receipt of the signed DNR, in accordance with facility policy, but this was not done.
A resident with dementia and other mental health diagnoses was prescribed an antipsychotic medication and received a new diagnosis of psychotic disorder with delusions. Despite these changes, the facility did not complete an updated PASARR screening as required by policy, and the Social Service Director confirmed that a follow-up screen should have been implemented.
Two residents with congestive heart failure did not have daily weights obtained as ordered, and significant weight changes were not reported to the physician as required. Staff failed to document weights on specific days and did not notify the physician when weight increases exceeded the parameters set by medical orders, despite clear facility policy and care plans requiring these actions.
A resident with a history of blood clots was admitted with hospital orders to continue Eliquis, but the medication order was not transcribed into the MAR, resulting in a five-day delay in administration. The required second nurse review and sign-off on admission orders was also not completed, leading to a significant medication error.
The facility failed to ensure food safety in the kitchen, affecting all 52 residents. Observations revealed expired poultry, improperly thawed turkey, and other expired food items. Interviews indicated staff were aware of the issues but did not follow the facility's food labeling and dating policy.
Failure to Update Advanced Directives in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were accurately updated and reflected in the medical record. The resident, who had multiple diagnoses including right hip fracture, cognitive communication deficit, metabolic encephalopathy, chronic kidney disease, chronic obstructive pulmonary disease, congestive heart failure, and atrial fibrillation, had a care plan indicating the presence of advanced directives. However, the care plan did not specify the details of these directives. The interventions listed included reviewing advanced directives quarterly and as needed, maintaining code status as ordered, and honoring the durable Power of Attorney's (POA) decisions. Despite a current physician's order indicating the resident was to be a full code, an out-of-hospital DNR form had been completed and signed by the resident's POA and physician, indicating the resident did not want CPR and wished to have a DNR code status. Interviews with nursing staff and the ADON confirmed that the code status in the electronic medical record should have been updated upon receipt of the signed DNR form, but this was not done. Facility policy required confirmation of code status and obtaining a physician's order as part of the medical record, which was not followed in this instance.
Failure to Complete PASARR After New Mental Health Diagnosis and Antipsychotic Prescription
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was completed when a resident received a new mental health diagnosis and was prescribed an antipsychotic medication. The clinical record review showed that the resident had multiple diagnoses, including dementia, anxiety disorder, depression, and later, a psychotic disorder with delusions due to a known physiological condition. The initial PASARR Level I indicated no need for a Level II review, as only anxiety disorder and depression were present at that time. However, after the resident was prescribed quetiapine, an antipsychotic medication, and received a new diagnosis of psychotic disorder with delusions, no updated PASARR screening was conducted. The Social Service Director confirmed that the PASARR did not reflect the new medication or diagnosis and acknowledged that another screen should have been implemented. Facility policy requires that a change in status, such as a new diagnosis or medication, triggers a Level II PASARR follow-up, which was not completed in this case.
Failure to Obtain Daily Weights and Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to obtain daily weights as ordered and did not notify the physician of significant weight changes for two residents with congestive heart failure and other complex medical conditions. For one resident, daily weights were ordered with specific parameters for physician notification in the event of a weight gain of 2 pounds or more in one day or a change of 5 pounds in one week. The resident was not weighed on two separate days, and there was no documentation that the physician was notified of the missed weights, despite the resident and her daughter expressing concerns about increased swelling and weight gain. The Executive Director confirmed that a new daily weight order was not properly saved in the system, resulting in a missed weight, and the reason for another missed weight was unknown. For the second resident, daily weights were also ordered with similar notification parameters. The clinical record showed multiple instances where the resident's weight increased by more than 2 pounds in one day, but there was no documentation that the physician was notified of these changes. Staff interviews confirmed that daily weights were to be obtained and recorded in the Medication Administration Record, and that staff were responsible for ensuring completion and documentation. The facility's policy required daily weights as ordered and a multidisciplinary approach to weight monitoring, but this was not followed for the residents reviewed.
Failure to Administer Anticoagulant as Ordered Due to Admission Order Transcription Error
Penalty
Summary
A deficiency occurred when a resident with a history of deep vein thrombosis, peripheral vascular disease, hyperlipidemia, anemia, and hypertension was admitted from the hospital with orders to continue Eliquis (apixaban) 5 mg twice daily. The hospital discharge note and physician's order both specified the need for this anticoagulant medication. However, the medication order was not transcribed into the Medication Administration Record (MAR) upon admission, resulting in the resident not receiving Eliquis for five days after admission. The omission was discovered during a chart review, and it was noted that the admitting nurse's checklist lacked a required second nurse signature. Facility policy required a second nurse to review and sign off on admission orders within 24 hours, but this did not occur. Interviews with staff confirmed that hospital discharge medication orders should be entered into the computer and reviewed according to policy, but this process was not followed, leading to the significant medication error.
Food Safety and Handling Deficiencies
Penalty
Summary
The facility failed to ensure food safety in the kitchen, affecting all 52 residents who consumed food prepared there. During an observation, it was noted that two containers of poultry with a use-by date of 4/21/24 were still in the walk-in cooler on 4/22/24. Additionally, a package of turkey was found thawing improperly in a large silver sheet pan with a reddish-brown liquid underneath, and neither the turkey nor the pan was dated. Other items, including pizza dough and a jar of base-ham, were found with expired use-by dates, and a bag of french fries in the walk-in freezer also had an expired date. Interviews with dietary staff revealed that they were aware of the expired use-by date on the chicken but still intended to use it. The Dietary Manager admitted that the labels were misprinted and that the staff, described as young and inexperienced, had made errors in labeling and discarding food items. The facility's policy on food labeling and dating, dated 4/26/22, was not followed, leading to these deficiencies in food handling and safety.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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