Wabash Senior Living & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: 09/16/2025. This Focus area includes the interventions of: serve diet as ordered and encourage oral intake. 2. R29's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: The diet spreadsheet dated day 9 lunch documents: pureed country fried steak # 6 scoop (5.33 ounces), thick cream gravy 2 ounces, mashed potatoes with thick gravy #8 scoop, pureed seasoned pasta #8, pureed buttered soft bread #16, and pureed mandarin oranges #10. The diet spreadsheet dated day 9 lunch dental soft (mechanical soft) documents: ground country fried steak with cream gravy #8 scoop (4 ounces), mashed potatoes with gravy #8 scoop, seasoned pasta #8 scoop, buttered soft bread 1 slice, and Mandarin oranges #8 scoop. The diet spreadsheet dated day 12 lunch documents: pureed panko mustard chicken #6 scoop, pureed scalloped potatoes #8 scoop, pureed pickled beets #12 scoop, pureed buttered bread #16 scoop and pureed peach parfait #8 scoop. The diet spreadsheet dated day 12 lunch dental soft (mechanical soft) documents:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). The findings include:R1's admission Record documents an admission date of [DATE] and includes diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia and Hypoxia, Nonrheumatic Tricuspid Insufficiency, Obstructive Sleep Apnea, Atelectasis, Oxygen Dependent, Pulmonary Hypertension, Peripheral Vascular Disease, and Chronic Kidney Disease. R1'S MDS Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section GG documents R1 is dependent on staff for hygiene, bathing, and dressing. Transfers were not attempted due to medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: 1. R20's Face Sheet documented an admission date of 11/20/2024 and included diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. This same document listed a discharge date of 12/5/24. R20's last transmitted MDS was an admission assessment and was completed on 11/27/24. 2. R25's Face Sheet documented an admission date of 10/29/2024 and included diagnoses of repeated falls, anemia, type 2 diabetes, and muscle weakness. This same document listed a discharge date of 11/26/24. R20's last transmitted MDS was an admission assessment and was completed on 11/5/24. On 4/23/25 at 11:00 AM, V4 (MDS Coordinator) stated that she just took over this job in March of 2025 and recognizes that R20 and R25's assessments are showing up as overdue quarterly assessments, however a discharge assessment should have been completed and transmitted with a due date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. R83's admission Record documented an admission date of 3/13/2024 and included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood, anxiety disorder, unspecified, and unspecified atrial fibrillation. R83's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, which indicates severe cognitive impairment. R83's Physician Order Summary documented divalproex (seizure and/or mood stabilization treatment) oral tablet delayed release 500mg (milligrams) -1 tablet by mouth twice a day, acetaminophen (pain reliever) oral tablet 500mg-give 2 tablets by mouth two times a day and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: R1's admission Record documents R1 was admitted to the facility on [DATE] and includes diagnoses of cerebral aneurysm, non-ruptured, contracture of muscle, multiple sites, adult failure to thrive, altered mental status, delusional disorder, generalized anxiety disorder, and Paroxysmal Atrial Fibrillation. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 01, indicating R1 has severe cognitive impairment. The same MDS documents that R1 has impairment on both upper and lower extremities, is dependent for showers, bed to chair transfers, and getting in and out of shower. R1's Care Plan documents that R1 has an ADL (Activities of Daily Living) self-care performance deficit. Documented interventions include that R1 requires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R1's Face Sheet documented an admission Date of 5/19/23 and listed diagnoses including Unspecified Dementia, Severe, with Anxiety, Chronic Obstructive Pulmonary Disease, Depression, and Hypertension. Elopement Risk Assessments for R1 were completed on 10/5/23 and 11/10/23. The Elopement Risk Assessments document the following: Residents are at a high risk for elopement when yes is answered to both questions in section A or a score of 5 or greater. R1's Elopement Risk assessment dated [DATE] documents a score of 19.5 and R1's Elopement Risk assessment dated [DATE] documents a score of 18.5, indicating R1 is a high risk for elopement. Both questions in section A of the Elopement Risk Assessments completed on 10/5/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 (R1) of 3 residents reviewed for discharge procedure in the sample of 3. Findings include: 1. R1's face sheet documented R1 was admitted to the facility on [DATE] with diagnoses including: pneumonitis due to inhalation of food and vomit, dysphagia, unspecified intellectual disorders, autistic disorder, insomnia. R1's care plan documented R1 had several physical behaviors such as hitting, pinching, and biting staff. R1's 6/22/23 Minimum Data Set (MDS) documented R1 was severely cognitively impaired. On 8/24/23 at 10:11 AM, V1 (Administrator) said R1 was admitted after a hospital stay due to aspiration pneumonia. V1 said R1 was going to work with speech therapy and be discharged back to the group home R1 was residing prior to hospital stay. On 8/24/23 at 12:29 PM, V2 (R1's Legal Guardian) said R1 was living in a group home and was transferred to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.