Wabash Senior Living & Rehab

possessions.

personal property for 1 of 1 resident (R80) reviewed for resident rights in a sample of 40.Findings

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.On 5/18/2026 at approximately 9:15am, R80 said about a week ago, he was moved to this new room on a different hall because he and his roommate got into a fight. R80 said the facility did not move his belongings when they moved him and it has been over a week since he had access to his belongings. R80 said he was very mad at the facility for not moving his belongings yet. R80 said he's been asking for the staff to bring his belongings to his new room every day since moving, but they had not done it yet. R80's Progress Note in the medical record dated 5/11/2026 at 15:28 (3:28pm), documented R80 and his roommate had an altercation and R80 was temporarily moved to a new room.On 5/19/2026 at 10:30am, V5 (Housekeeper) was cleaning rooms on the hall where R80 previously resided. V5 said R80 moved to a different hall about a week ago. V5 entered R80's old room on the previous hall and verified R80 did not have his personal belongings yet as the belongings were still in the old room. V5 said she would move the belongings after while when she could get to it.On 5/19/2026 at 11:30am, V6 (Housekeeper) said on 5/11/26, R80 was moved to a different hall. V6 said the housekeeping staff are responsible for moving resident belongings when they move rooms and should have moved R80's belongings the same day he was moved. V6 said that is how things are usually done.On 5/19/2026 at 11:30am, R80's personal belongings were observed to still be in R80's old room and had not been moved to R80's new room on a different hall.On 5/19/2026 at 11:46am, V3 (Corporate Administrator) was asked what he felt was a reasonable time for a resident to wait before their personal belongings were moved due to a room change and V3 answered, 8 days.On 5/19/2026 at 12:24pm, V7 (Housekeeper) said when a resident moves from one room to another room, their belongings are moved immediately to the new room by housekeeping staff. On 5/20/2026 at 3:00pm, R80 was observed with his personal belongings in his new room.

The facility's admission contract under the section titled Residents' Rights documents the following in part: As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal laws.

Your personal property rights, you have the right to keep and wear your own clothing, you may keep and use your own property, you have the right to expect your facility to have a safe place where you can keep small valuables which you can get too daily.

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Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821

deteriorating from 3/17/26 to 3/31/26. V4 stated on 3/18/26, V16 (Wound NP) asked me if insurance covered a new treatment she wanted to order. V4 stated the insurance did not cover it so they continued the same treatment. V4 stated V16 was supposed to assess R6 on 3/25/26 but couldn't because her children were sick.

When asked if any physician was notified of the deterioration of the pressure ulcer, V4 stated, I would not say so. V4 stated the physician should have been notified.

When asked if any physician was notified of the deterioration of the pressure ulcer from 5/15/26 to 5/20/26, V4 stated, Not that I see.

When asked if she would expect a physician to be notified, V4 stated, Oh yeah, definitely.

When asked if she had any concerns with wound care at the facility, V4 stated she didn't. V4 stated they are normally good about notifying the physician if a wound/pressure deteriorates. On 5/26/26 at 12:15 PM, when asked if she was notified of a deterioration in the pressure ulcer from 5/15/26 to 5/20/26, V16 (Wound Nurse Practitioner) stated she completed a chart review on 5/14/26 but wasn't notified of any deterioration from 5/15 to 5/20/26. V16 stated when she assessed R6 on 5/20/26, she noted a foul odor in the wound, R6 appeared sick, and was tachycardic. V16 stated the pressure ulcer needed debrided and with R6's history she had her admitted to the local hospital for surgical debridement in the operating room. V16 stated when they did the debridement the bone was exposed.

This surveyor asked if R6 had osteomyelitis and V16 stated she was surprised that she didn't, but all the tests were negative.

When asked if she had any concerns with wound care at the facility, V16 stated she thought they did a great job with wound care, but they needed protocols in place on when to get the wound specialist involved. On 5/26/26 at 10:44 AM, V17 (Physician) stated he thought wound care specialists were seeing R6 from 5/15/26 to 5/20/26. V17 stated he remembered talking with the facility earlier in May and they were worried about the area but V16 (Wound Nurse Practitioner) was following the pressure ulcer and had made treatment order changes. V17 stated he didn't have any documentation or remember being notified of a deterioration from 5/15 to 5/20/26.

The undated facility Guidelines for Notifying Physicians of Change of Condition documents, These guidelines are intended to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and that 2) all significant changes in the resident's status are assessed, documented in the medical record and communicated with the primary care physician.The charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management.

The undated facility Assessment and documentation of wounds policy documents, The purpose of this procedure is to provide information to the primary care provider and the resident representative regarding identification of wounds/wound characteristic changes and interventions for specific risk factors.1.

Report changes in wound characteristics to the PCP (primary care physician) and the resident representative.3.

Document the interaction in the progress notes including the PCP whom was contacted and the resident representative.

The Immediate Jeopardy that began on 3/23/26 was removed on 5/27/26 when the facility took the following actions to remove the immediacy: The facility has implemented and educated staff on notifications of the PCP (primary care physician) of changes in wound condition: Licensed Facility personnel will be or have been educated by the Administrator, (V1), DON (V4), and Regional Nurse (V21) to ensure that they are aware of policy rela

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Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821

(R42) yelled get your hands off my shit shortly after, the call light came on, as I was walking down to investigate.

Upon entering the room, I observed both residents on their own respective sides of the room. (R42) stated that (R38) was getting into her things so she said to get her hands off her shit and (R42) said that (R38) attacked her. (R42) stated that she was grabbed violently, shoved and scratched. I observed a cut on the (left) forearm of (R42). I immediately notified the nursing and followed her instructions.On 5/21/2026 at 11:45am, V11 said he was at the nurse's station when he heard yelling from R42. V11 said when he entered R42's room, R38 and R42 had been arguing and R42 said R38 attacked her by violently grabbing her left wrist, hit, scratched and shoved her. V11 said R42 was scared of R38, and he escorted R38 to another room for the night. V11 said R42 had cuts on her left wrist and was bleeding, but the nurse cleaned and dressed her wounds.On 5/21/2026 at approximately 11:00am, V1 (Administrator) said he was still investigating the incident of 5/19/2026 between R38 and R42 and could not say at this point in the investigation if resident to resident abuse had occurred. V1 also said he could not say whether he would or would not substantiate if abuse had occurred for this investigation.The facility policy titled Abuse Prevention dated 8/16/2025 documents the following in part: this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.

This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends and any other individuals.

Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

Physical abuse includes but is not limited to, hitting, slapping, punching, biting and kicking.

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Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821

documents Non-pressure chronic ulcer of right calf, unspecified ulcer stage.

Under Plan documents Some sloughing on the wound bed.

Will do triad every other day and cover with dry dressing.

May switch to collagen next week.

Obtain arterial and venous dopplers.R9's Order Summary Report dated 4/1/26 to 5/21/26 includes the following physician orders: Cleanse right calf with normal saline, pat dry, apply triad and cover with dry dressing. In the morning every other day for Wound care with a start date of 4/22/26 and no discontinue date documented but discontinued documented under order status.On 5/26/26 at 3:00 PM, V4 (Director of Nurses) stated she assumed V17 (Physician) was notified when the area was first identified and V16 (Wound Nurse Practitioner) was notified after that.

V4 stated V16 was coming every two weeks but comes weekly now.

This surveyor reviewed R9's Skin Issue report dated 4/17/26 when it documents the wound deteriorated and asked V4 if any physician was notified of the deterioration. V4 stated, No, just 4/21/26.

When asked why a physician was not notified of the deterioration V4 stated, lack of communication.

When asked who the lack of communication was between, V4 stated the floor nurses know to let the nurse manager, power of attorney, and physician know if an area deteriorates. V4 stated they (administration) should have caught it when they came to work on 4/18/26. V4 stated she would expect the nursing staff to make all necessary notifications when a wound is deteriorating. V4 stated there was no communication documented with V17 (Physician). V4 stated the facility staff should have called V17.On 5/27/26 at 10:44 AM, V17 (Physician) stated he didn't have any documentation from 4/7/26 to 4/17/26 and didn't have documentation that he had ordered a treatment for the wound. V17 stated he typically goes along with whatever the facility recommends for treatments.V16's (Wound Nurse Practitioner) Progress Note for R6 dated 5/6/26 documents, She did have arterial Dopplers that showed severe arterial stenosis of the bilateral lower legs.

She is allergic to contrast dye but does have a referral placed for vascular surgery.Assessment: 1.

Peripheral artery disease. 2.

Arterial leg ulcer. 3.

Skin tear of left lower leg without complication, subsequent encounter.Plan: Switch dressings to right lower leg to Medihoney and collagen.

Cover with dry dressing.

Change every other day.On 5/21/26 at 9:56 AM, V30 (Licensed Practical Nurse/LPN) administered treatments with V2 (Infection Preventionist) present. V30 cleaned the wound on the back of R9's right calf with normal saline, patted it dry, covered with medihoney, collagen powder, and covered with a border foam dressing using current standards of practice.

The area was open with slough present. V30 and V2 stated it started as a skin tear, and they didn't know how it deteriorated.On 5/26/26 at 12:05 PM, V16 (Wound Nurse Practitioner) stated she was notified of the wound to R9's right lateral calf on 4/21/26 and saw her on 4/22/26. V16 stated there were no orders for treatment prior to that.

When asked when she would expect to be notified of a new area. V16 stated ideally, I would have liked to have seen her on 4/10/26 but for sure on 4/17/26 when it looked a lot worse.

When asked how they knew what treatment to administer if she hadn't seen her, V16 stated, I don't know if they have protocols in place.

When asked if she had seen her sooner and treatments had been implemented if the outcome would be different, V16 stated if she had been notified, she would have ordered something and hopefully prevented it from getting to the sloughy way it looked on 4/17/26. V16 stated after it was treated with triad it looked better and smaller.The facility undated Treatments/Wound Care policy documents, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.

Preparation: 1.

Verify that there is a physician's order for this procedure.Reporting: 1.

Notify the supervisor if the resident refuses the wound care. 2.

Report other information in accordance with facility policy and professional standards of practice.

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Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821

foul odor in the wound, R6 appeared sick, and was tachycardic. V16 stated the pressure ulcer needed debrided and with R6's history she had her admitted to the local hospital for surgical debridement in the operating room. V16 stated when they did the debridement the bone was exposed.

This surveyor asked if R6 had osteomyelitis and V16 stated she was surprised that she didn't, but all the tests were negative.

When asked if she had any concerns with wound care at the facility, V16 stated she thought they did a great job with wound care, but they needed protocols in place on when to get the wound specialist involved. On 5/26/26 at 10:44 AM, V17 (Physician) stated he thought wound care specialists were seeing R6 from 5/15/26 to 5/20/26. V17 stated he remembered talking with the facility earlier in May and they were worried about the area but V16 (Wound Nurse Practitioner) was following the pressure ulcer and had made treatment order changes. V17 stated he didn't have any documentation or remember being notified of a deterioration from 5/15 to 5/20/26. 2. R6's Wound Ostomy Eval and Treat note with a service date of 4/5/26 documents, Left posterior heel: area of callous-like skin with circumferential blanchable erythema.

Unknown etiology but cannot r/o (rule out) pressure component.

Recommendations: Left heel- 1.

Cleanse wound with soap and water daily.

Use remedy cleanser in green and white bottle. No Hibiclens. 2.

Cover with a 4x4 foam bordered (mepilex) dressing.

Date and time dressing. 3.

Remove dressing daily to cleanse and assess wound then reapply. 4.

Dressing should be changed when drainage is visible to the edges of the foam pad. It may be used for up to 7 days. 5.

Notify physician. for no improvements or concerns. R6's Skin Issues report dated 4/11/26 does not document an area to R6's left heel. R6's Order Summary Report dated 6/1/26 does not document treatment orders or preventative measures for the area to R6's left heel.

R6's Skin Monitoring: CNA (Certified Nurse Assistants) Shower Review sheets dated 5/1, 5/4, 5/6, 5/8, and 5/15/26 do not document an area on R6's left heel. On 5/19/26 at 8:12 AM, V18 (LPN) administered treatment to R6's abdominal fold with V4 (DON) present.

After the treatment was completed per current standards of practice, this surveyor asked R6 if she had any other pressure ulcers/sores. R6 stated she did on her heels.

This surveyor observed both feet lying flat on the bed.

When asked if they did treatments on her heels, R6 stated they were usually propped up on pillows.

When asked why they weren't propped up now R6 responded that she wasn't sure.

When asked how long they had been flat on the bed, R6 stated, since last night.

This surveyor, with the assistance of V18, observed both of R6's heels.

The right heel was pink/red with no open areas or sores.

The left heel had a dark red/black area that was closed and soft to touch (per V18/LPN).

When asked if they were aware of the area prior to this observation, V18 and V4 both stated they were not. R6's Progress Notes document the following:5/19/26 at 2:00 PM, Resident stated t

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Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821

prevent accidents.

interview, observation, and record review, the facility failed to implement care plan fall interventions

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.

R81's Fall Risk assessment dated [DATE] documents a fall risk score of 14 indicating R81 continues to be at risk for falls.

R81's Care Plan documents a focus area for increased risk of falls.

Interventions for this focus area includes an assist bar added to left side of bed to assist with balance before standing dated 11/14/25.

On 5/20/26 at 9:41 AM, R81's bed was observed, with V9 (Memory Care Director) present, to have no assist bar on either side of R81's bed. V9 (Memory Care Director) verified there was no assist bar on either side of R81's bed.

This surveyor and V9 verified R81's most recent care plan in her electronic health record an assist bar to the left side of R81's bed is listed as a fall intervention. V9 agreed R81 should have the assist bar on her bed if it is a fall intervention. V9 denied the lack of an assist bar increased R81's risk of falls because she is strong and has good mobility.

However, V9 did agree if the assist bar is ordered as a fall intervention, then it should be in place on R81's bed.

On 05/21/2026 at 8:20 AM, an assist bar was observed attached to R81's bed frame.

On 5/21/26 at 8:23 AM, V14 (Registered Nurse) stated she does remember seeing R81's assist bar on side of her bed in the past but can't remember the last time she saw it. V14 stated she would expect the assist bar to be on the bed if ordered or implemented as a fall precaution. V14 stated one of the possible risks if an assist bar isn't on the bed frame would be an increased risk of falls/injuries.

On 5/21/26 at 12:54 PM, V1 (Administrator) stated he is familiar with R81, but he is not familiar with her fall precautions without looking them up. V1 stated he would expect the fall precaution of an assist bar to be implemented if recommended by the interdisciplinary team or ordered by the physician. V1 stated if it is not implemented or removed it could increase R81's risk for falls or injuries from falls.

The facility's fall policy with a revision date of March 2018 documents, Staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

The same document includes staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

menus.

Such tools include the 2010 Dietary Guidelines for Americans publication/recommendations

146019 06/03/2026

Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821