Wabash Senior Living: Immediate Jeopardy Wound Failure - IL
The resident, identified in inspection records only as R6, had been living at Wabash Senior Living & Rehab on College Boulevard when federal inspectors arrived on June 3, 2026. What they found triggered an immediate jeopardy citation, the most serious classification available under federal nursing home oversight, reserved for situations where a facility's failures have placed residents in serious harm or at risk of death.
The nursing home is disputing the citation.
R6 had returned to the facility from a hospital stay on February 16, 2026, with an abrasion to her right gluteus. Staff treated it with xeroform, a medicated gauze dressing, until the facility's physician, identified in the report as V17, changed the order on February 24 and referred her to a wound specialist. The wound nurse practitioner, V16, assessed R6 on March 11 and ordered a new treatment called triad.
Then the wound started getting worse. And nobody called the doctor.
Inspection records show the pressure ulcer was documented as deteriorating from March 17 through March 31. The director of nursing, identified as V4, told inspectors that on March 18, the wound nurse practitioner had asked whether insurance covered a new treatment she wanted to try. It didn't. So the facility kept using the same treatment that wasn't working. The wound nurse practitioner was supposed to reassess R6 on March 25, but V4 told inspectors she couldn't come in because her children were sick.
When the inspector asked V4 whether any physician had been notified of the deterioration during that stretch, from March 17 to March 31, V4 said, "I would not say so." She added that the physician should have been notified.
The wound continued to worsen into May. Inspection records document further deterioration from May 15 through May 20. The inspector asked V4 whether any physician had been notified during that window. "Not that I see," V4 said. The inspector asked whether she would expect a physician to be notified under those circumstances. "Oh yeah, definitely," V4 said.
When the inspector asked V4 whether she had any concerns about wound care at the facility, she said she didn't. She said they were normally good about notifying the physician when a wound deteriorates.
The physician, V17, told inspectors on May 26 that he thought wound care specialists had been seeing R6 throughout the May 15 to May 20 period. He said he remembered talking with the facility earlier in May and that staff had expressed concern about the area, but that V16 was following the wound and had been making treatment order changes. He told inspectors he had no documentation of being notified about the deterioration during that period and didn't remember receiving any notification.
V16, the wound nurse practitioner, told inspectors she had completed a chart review on May 14 but was not notified of any deterioration between May 15 and May 20. When she came to assess R6 on May 20, she noticed a foul odor coming from the wound. R6 appeared sick. Her heart rate was elevated. V16 determined the wound needed to be surgically debrided and, given R6's history, had her admitted to the local hospital for the procedure.
The surgery was performed in an operating room. When the surgical team debrided the wound, the bone underneath was exposed.
The inspector asked V16 directly whether R6 had osteomyelitis, the bone infection that can follow when a wound reaches that depth. V16 said she was surprised, but that all the tests came back negative.
When asked whether she had concerns about wound care at the facility, V16 said she thought staff did a great job. But she said the facility needed protocols in place specifying when to bring in a wound specialist.
The facility had a written policy. It said that changes in wound characteristics should be reported to the primary care physician and the resident's representative, and that the interaction should be documented in the progress notes, including the name of the physician who was contacted. A separate guidelines document said the charge nurse or supervisor should contact the attending physician when a clinical situation appears to require immediate discussion and management.
Nobody had.
The inspection report includes a note from V24, whose role is not specified in the available records, who told inspectors: "Do I think there wasn't anything done, I think there was but not fast enough, obviously."
The immediate jeopardy designation, which began on March 23, 2026, was lifted on May 27, one day after inspectors conducted their on-site interviews. The facility told inspectors it had educated licensed personnel, including the administrator identified as V1, V4 the director of nursing, and a regional nurse identified as V21, on the requirement to notify the primary care physician when a wound condition changes.
The gap between what the policy said and what staff did runs through the entire inspection record. The facility's own documentation required physician notification. The director of nursing told inspectors a physician should have been notified, that she would definitely expect a physician to be notified, and then said she had no concerns about wound care. The wound nurse practitioner said staff did a great job. The physician said he thought someone else was handling it.
R6 had come back from the hospital in February with a wound to her backside. By May, a surgeon was in an operating room scraping infected tissue away from her bone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wabash Senior Living & Rehab from 2026-06-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
WABASH SENIOR LIVING & REHAB in CARMI, IL was cited for immediate jeopardy violations during a health inspection on June 3, 2026.
The nursing home is disputing the citation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.