Wabash Senior Living & Rehab

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician when a pressure ulcer deteriorated for 1 (R6) of 4 residents reviewed for physician notification in the sample of 40. This failure resulted in an abrasion to the right gluteus progressing to a Stage 4 pressure ulcer that became infected, requiring R6 to be hospitalized with sepsis on two occasions and requiring surgical wound debridement. The Immediate Jeopardy began on 03/23/2026 when R6's wound was identified as deteriorating and the physician was not notified to obtain new treatments or implement new interventions. The Administrator (V1) and the [NAME] President of Clinical Services (V21) were notified of the Immediate Jeopardy on 5/27/26 at 2:36 PM. [...]

Inspectors wroteBased on interviews, record review, and observation the facility failed to prevent resident to resident physical abuse for 1 of 1 (R42) residents reviewed for abuse in a sample of 52. This failure resulted in R42 being attacked on 5/19/2026 by R38, causing a skin tear to her left wrist, bruise to her left thumb, and becoming fearful for her safety. Findings Include:R42's admission Record documents an admission date of 12/18/2025 with diagnoses of type 2 diabetes mellitus without complications, unsteadiness on feet, need for assistance with personal care and muscle weakness among others. R42's MDS (Minimum Data Set) dated 3/24/2026 documents R42 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15 which indicates R42 is cognitively intact. This same MDS documents R42 uses a walker for ambulation and is independent with most activities of daily living. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure an effective treatment was implemented for a newly identified wound and report worsening of the wound for 1 of 4 (R9) residents reviewed for quality of care in the sample of 40. This failure resulted in deterioration of R9's arterial wound to the right leg. Findings Include:R9's admission Record with a print date of 5/26/26 documents R9 was admitted to the facility on [DATE] with diagnoses that include iron deficiency anemia, depression, cognitive communication deficit, muscle weakness, hypertension, diabetes, and chronic obstructive pulmonary disease. R9's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 03, indicating a severe cognitive deficit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain orders and implement interventions for 1 (R6) of 4 residents reviewed for pressure ulcers in the sample of 40. This failure resulted in an abrasion to the right gluteus deteriorating and becoming infected, requiring R6 to be hospitalized with sepsis on two occasions and requiring surgical wound debridement and the development of a Stage 2 pressure ulcer on R6's left heel. Findings Include:1. R6's admission Record with a print date of 5/26/26 documents R6 was admitted to the facility on [DATE] and included diagnoses of major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and pressure ulcer of left heel. R6's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R6 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to promote dignity for 4 of 7 (R9, R29, R50, and R54) residents reviewed for resident rights in the sample of 40. Findings Include: 1. R9's admission Record with a print date of 5/21/26 documents R9 was admitted to the facility on [DATE] with diagnoses that include dysphagia, depression, cognitive communication deficit, and diabetes. R9's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03, indicating a severe cognitive deficit. R9's current Care Plan documents a Focus area of, Nutritional Risk r/t (related to) dx (diagnosis) DM (diabetes mellitus) type 2, depression. Below IBWR (ideal body weight range) with recent wt (weight) gain. Varied intake leaves 25% or more uneaten. 4/10/26 change from reg (regular) cons (consistency) to mech (mechanical) soft. Date Initiated: [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to follow the menu and serve the complete serving size of altered diet textures for 5 (R9, R18, R34, R64, R87) of 5 residents reviewed serving sizes in a sample size of 40.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide a resident access to personal property for 1 of 1 resident (R80) reviewed for resident rights in a sample of 40. Findings Include:R80's admission Record documents an admission date of 6/27/2025 with diagnoses of type 2 diabetes mellitus, muscle weakness, dysphagia and venous insufficiency among other. R80's MDS (Minimum Data Set) dated 3/13/26, documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15 total which indicates R80 is cognitively intact. This same MDS documents R80 has impairment to bilateral legs, uses a wheelchair for locomotion, is dependent on staff for toileting and needs substantial/maximum assistance with showers and dressing. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to implement care plan fall interventions for 1 of 6 residents (R81) reviewed for accidents in the sample of 40. Findings Include: R81's admission Record documents an admission date of 12/1/23 with diagnoses including dementia, Alzheimer's disease, repeated falls, insomnia, and polyneuropathy. R81's Minimum Data Set (MDS) dated [DATE] documents R81 has a Brief Interview for Mental Status (BIMS) score of 99 indicating resident was unable to answer questions due to her poor cognition which puts her at risk for poor self-safety awareness. The same MDS documents R81 requires assistance of a walker for ambulation, requires supervision and/or touch assist for transfers from bed to chair, sitting to standing and transition from lying to sitting on side of bed, and R81 has a history of falls. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain equipment that was present on the crash cart and available for use for 1 of 3 residents (R1) reviewed for emergency events in a sample of 36. This failure has the potential to effect 32 residents (R4-R36) residing in the facility with active orders to attempt resuscitation/CPR (Cardiopulmonary Resuscitation).

Inspectors wroteBased on interview and record review, the facility failed to timely transmit Minimum Data Set (MDS) Assessments for 2 (R20 & R25) of 2 residents reviewed for timely MDS submission in the sample of 45.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received the correct medications in accordance with their physician's orders for 2 (R83, R92) of 7 residents reviewed for significant medication errors in the sample of 45. This past noncompliance occurred between 3/17/2024 and 4/1/2025.

Inspectors wroteBased on interview and record review, the facility failed to transfer a resident safely for 1 (R1) of 3 residents reviewed for accidents in the sample of 6. This past non-compliance occurred between 12/01/2024 to 12/13/2024.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered as ordered for 1 (R77) of 10 residents reviewed for medication administration in the sample of 38. This failure resulted in R77 experiencing a significant medication error in which 5 additional doses of diuretic medication were administered resulting in dizziness, abnormal lab values, Intravenous Fluid administration, supplemental Potassium medication, and a hospital admission for an Acute Kidney Injury. This past non-compliance occurred between 3/14/24 and 3/19/24. Findings Include: R77's admission Record documented R77 was [AGE] years old with an admission date to the facility of 03/08/2023. Diagnoses listed in their entirety on this document are: Alzheimer's Disease with late onset; Essential Hypertension; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a window alarm was in working order for a resident at a high risk for elopement for 1of 3 residents (R1) reviewed for elopement in the sample of three. This past non-compliance occurred between 11/9/23 and 11/16/23.