Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wabash Senior Living & Rehab during CMS and state inspections, most recent first.
Failure to Notify MD of Worsening Wound: A resident with multiple comorbidities and a pressure injury had a right gluteal abrasion that progressively worsened from an open wound to a stage IV ulcer with drainage, odor, slough, and exposed tissue. Staff documented the decline in skin assessments and notes, but there was no reproducible evidence that the MD was notified when the wound first deteriorated. The wound later became infected and required hospital transfer for surgical debridement.
Failure to protect a resident from resident-to-resident physical abuse: one resident entered another resident’s area, got into her belongings, and then grabbed, hit, and scratched her left wrist/hand, causing a skin tear, bruise, swelling, and pain. The injured resident said she was afraid of the other resident, while staff heard yelling, found both residents in the room, separated them, and documented the wound and bruising. The other resident had dementia with behavioral disturbance and used a walker and wheelchair.
A resident with severe cognitive impairment and multiple chronic conditions developed a new unstageable wound to the right calf that worsened over time. Staff entered wound care orders that did not clearly match the wound location, and the DON acknowledged staff would not know how to identify the wound from the order as written. The physician later stated he had no documentation of ordering treatment, and the wound NP noted the wound was worsening and that there were no wound orders in place when she evaluated it. The DON also acknowledged a lack of communication when the wound deteriorated.
A resident with multiple comorbidities and limited mobility developed a worsening right gluteal wound that progressed from an abrasion to an infected Stage 4 pressure ulcer with foul odor, purulent drainage, and sepsis requiring hospital transfer and surgical debridement. Staff documentation showed the wound deteriorated over time, but the facility could not show that the MD was properly notified of the changes or that timely action was taken. A left heel area also lacked documented treatment or prevention measures, and surveyors later observed a dark red/black area on the heel while the resident’s heels were flat on the bed.
Failure to Serve Assisted Residents Meals with Dignity: A group of residents with severe cognitive impairment and care plans addressing nutritional risk and dignity were seated together for meals, but their trays were not served at the same time. Some residents waited while others at the same table were already eating, and one resident repeatedly asked where his food was before it arrived. The AD stated residents needing eating assistance should be served close to the same time and should not have to watch another resident eat.
Failure to Serve Full Portions of Altered Diets: Surveyors found the facility did not follow the menu or serve complete portion sizes for altered-texture meals. Residents on pureed and mechanical soft diets, including residents with dx such as dementia, dysphagia, malnutrition, GERD, and CVA history, were served partial scoops of entrées and sides instead of the full menu portions listed. The Administrator stated the menu should be followed and full scoops of mechanically altered diets should be served.
Failure to Provide Access to Personal Property After Room Change: A cognitively intact resident with DM2, muscle weakness, dysphagia, venous insufficiency, and mobility/ADL impairments was moved to a new room after an altercation with a roommate, but his belongings were left in the old room for over a week. The resident said he asked staff daily for his items, and housekeeping confirmed the belongings had not been moved when expected.
Failure to Implement Documented Fall Intervention: A resident with dementia, Alzheimer’s disease, repeated falls, poor cognition, and a high fall risk score had a care plan intervention for an assist bar on the bed, but surveyors observed the bed without the assist bar in place and the Memory Care Director verified it was missing. Staff and the Administrator stated the assist bar should be present if it was ordered as a fall precaution, and the facility policy required staff to identify and implement interventions related to the resident’s specific fall risks.
A resident with full-code status and significant cardiopulmonary conditions was found unresponsive, and an LPN initiated CPR while another LPN retrieved the crash cart and attempted to use the AED. The AED repeatedly announced a low battery and no pads could be found on the crash cart, so the AED could not be applied while staff continued manual compressions until EMS arrived. Interviews revealed that only one crash cart was available, the ADON was responsible for monthly checks, and the crash cart checklist did not include the AED. Staff reported the AED had been announcing a low battery for several months, the last set of pads had been used in a prior code and not replaced, and leadership, including the administrator and owner, were aware of the low battery but had not ensured timely ordering of a replacement battery and pads. The AED manufacturer’s manual required regular status checks and battery replacement when low, and facility policies required the emergency cart to be inventoried after each use, checked at least monthly with documentation, and to maintain CPR/BLS equipment at all times, while multiple residents in the facility had active CPR orders.
Two residents with multiple medical conditions did not have their required MDS discharge assessments transmitted by the mandated deadlines. The MDS Coordinator confirmed that the assessments were overdue, and validation reports showed that both were completed and submitted several months late, well beyond the required timeframe.
Two residents with severe cognitive impairment were given each other's medications when an RN, distracted during a med pass, mixed up unlabeled medication cups. One received donepezil in error, while the other received acetaminophen, valproate, and apixaban not intended for them. The incident was documented and reported per facility policy.
A resident with severe cognitive impairment and multiple medical conditions was improperly transferred by two CNAs without using the required mechanical lift, resulting in a large bruise on her forearm. The CNAs, unfamiliar with the resident's care needs, lifted her under the arms instead of using the lift, contrary to facility policy. The incident was reported to administration, and the resident's physician and POA were notified.
A resident experienced a significant medication error when Zaroxolyn was administered for ten days instead of the prescribed five days due to an incorrect order entry in the EMR system. This led to dizziness, abnormal lab values, and an Acute Kidney Injury, requiring hospital admission for treatment.
Failure to Notify Physician of Worsening Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician when a resident’s right gluteal wound deteriorated. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a pressure ulcer of the left heel, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with bed mobility and was dependent on staff for transfers. The care plan and MDS documented pressure injury risk, pressure-reducing devices, turning and repositioning, weekly skin assessments, and reporting abnormal findings to the PCP. The resident’s right gluteal abrasion was first identified after a hospital return and was treated with ordered wound care. The wound then worsened over time, with skin issue reports documenting deterioration, increasing size, non-healing tissue, pain, drainage, odor, slough, and exposed adipose tissue. A nurse note on 3/23 documented increased drainage, slough, foul odor, exposed adipose tissue, and that the resident needed to see a doctor and may need antibiotics, but the facility could not provide reproducible evidence that the physician was notified or what the physician ordered in response. Staff statements reflected that notes were placed for the physician to see, but documentation of actual notification was not available. The wound continued to decline after the 3/23 note, with later reports showing worsening odor, purulent drainage, bleeding, and rapid enlargement. The wound nurse practitioner later documented that the wound had significantly deteriorated and required debridement, and the resident was ultimately hospitalized for surgical debridement. Hospital records documented a stage IV pressure ulcer with infection and sepsis/shock, and the wound culture grew multiple organisms. The survey findings also included staff and physician interviews indicating that the physician had no documentation of notification during the period when the wound was worsening and that earlier notification could have allowed more aggressive treatment.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident physical abuse when one resident attacked another during the night, causing a skin tear to the left wrist, bruising to the left thumb, swelling, pain, and fear for safety. The injured resident was admitted with diagnoses including type 2 diabetes mellitus, unsteadiness on feet, need for assistance with personal care, and muscle weakness, and had a BIMS score of 15/15 indicating cognitive intactness. The other resident involved had diagnoses including type 2 diabetes mellitus, dementia with other behavioral disturbance, and essential hypertension, and used a walker and wheelchair for locomotion. According to the injured resident, she returned from the bathroom and found the other resident in her area getting into her refrigerator. When she told the other resident to get out of her things, the other resident became angry, grabbed her left wrist, hit her left hand, and scratched her, causing the injury. The injured resident stated she was afraid of the other resident and was glad the other resident had been moved to another unit so she could not hurt her again. At observation the next day, the resident’s left wrist/hand was bandaged, an observable bruise was present at the base of the left thumb, and the hand/wrist was slightly swollen and painful to touch. Facility documentation and staff statements confirmed that staff heard yelling from the room, found the residents in the room, and separated them. Nursing notes documented a skin tear with partial skin flap loss to the left wrist/forearm and bruising to the left thumb, with the wound cleansed and steri-strips applied. Staff statements described the other resident as being in the injured resident’s area and making unwanted contact, while the administrator stated the investigation was still ongoing and could not yet determine whether resident-to-resident abuse had occurred. The facility’s abuse prevention policy states residents are to be free from abuse by anyone, including other residents, and defines physical abuse as willful infliction of injury resulting in physical harm or pain.
Failure to Provide and Communicate Wound Treatment
Penalty
Summary
The facility failed to ensure effective treatment was implemented for a newly identified wound and failed to report worsening of the wound for one resident with multiple diagnoses including iron deficiency anemia, depression, cognitive communication deficit, muscle weakness, hypertension, diabetes, and COPD. The resident had severe cognitive impairment on the MDS and a care plan addressing impaired mobility and skin integrity concerns, including an unstageable pressure ulcer to the right lateral calf. The record shows the wound was identified as a new unstageable pressure ulcer/injury to the right lateral calf, acquired in the facility, with measurements documented on the skin issue report. The physician order record showed orders entered for dressing changes to the right lower leg, but the order descriptions did not match the wound location documented in the record, and one order was not signed by the physician until weeks later. The DON stated the treatment to the right lower inner leg was the treatment ordered for the wound on the right lateral calf, but also acknowledged staff would not know how to identify the wound location from the order as written. The physician stated he was notified of the area to the right lateral calf and implemented pressure-reducing interventions, but later stated he had no documentation from the relevant period and did not have documentation that he had ordered a treatment for the wound. The wound worsened over time, with progress notes documenting deterioration and later a wound nurse practitioner noting the wound was getting worse and that there were no wound orders in place when she evaluated it. The DON stated there was no communication documented with the physician regarding deterioration and acknowledged a lack of communication between staff. The wound nurse practitioner stated she would have liked to have seen the resident sooner and that earlier notification would have allowed her to order treatment that might have prevented the wound from becoming sloughy. The facility policy required a physician order for wound care and reporting information in accordance with facility policy and professional standards of practice.
Failure to Manage Worsening Pressure Ulcers and Document Physician Notification
Penalty
Summary
The facility failed to obtain orders and implement interventions for one resident with pressure ulcers, and the resident’s right gluteus abrasion deteriorated into an infected Stage 4 pressure ulcer. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a left heel pressure ulcer. The resident was cognitively intact, required substantial to maximal assistance to roll in bed, and was dependent on staff for transfers. The care plan and MDS identified pressure ulcer risk and included interventions such as turning and repositioning every 2 hours, pressure relief devices, heel floating, weekly skin assessments, and wound specialist involvement. The right gluteus wound was first identified as an abrasion and was treated with ordered dressings, but serial skin issue reports documented progressive deterioration, increasing size, pain, drainage, odor, and slough. The wound was described as non-healing and later as unstageable, with purulent drainage and foul odor. Staff interviews showed that changes in the wound were often placed on reports or left on the physician’s desk, but the facility was unable to provide reproducible evidence that the physician was notified of the worsening wound or what response was given. The wound nurse practitioner stated she was not notified of deterioration between follow-up visits and that earlier notification could have allowed more aggressive treatment. The wound continued to worsen until the resident required bedside and then surgical debridement, IV antibiotics, and hospital transfer for shock and sepsis related to the infected pressure ulcer. Hospital records documented a Stage 4 buttock pressure wound with polymicrobial infection and sepsis due to the pressure ulcer. In addition, a left heel area noted by wound evaluation as callous-like skin with blanchable erythema and possible pressure component did not have documented treatment orders or preventive measures in the resident’s record, and later survey observation found a dark red/black closed area on the left heel while the resident’s heels were lying flat on the bed.
Failure to Serve Assisted Residents Meals with Dignity
Penalty
Summary
The facility failed to promote dignity for 4 of 7 residents reviewed for resident rights. The affected residents included R9, R29, R50, and R54, all of whom had significant cognitive impairment documented in their records. R9 had diagnoses including dysphagia, depression, cognitive communication deficit, and diabetes, with an MDS BIMS score of 03. R29 had dementia, anxiety, and needed assistance with personal care, with a severe cognitive impairment on MDS. R50 had Alzheimer's disease, dysphagia, and adult failure to thrive, with an MDS BIMS score of 00. R54 had dysphagia, diabetes, and heart disease, and his care plan included respect for individual dignity and autonomy. During observation of the noon meal in the dining room, residents who required assistance with eating were seated together, but their meals were not served at the same time. On 5/18/26, R90 was served at 12:09 PM, R9 at 12:14 PM, R39 at 12:16 PM, R54 at 12:17 PM, and R29 did not receive a meal until 12:31 PM after staff asked where it was. On 5/19/26, R28 was served at 12:06 PM, while R9 repeatedly asked where his food was at 12:15 PM and 12:21 PM; R50 was not served until 12:33 PM, R54 at 12:40 PM, and R9 at 12:43 PM. The Activities Director stated the residents at those tables were the ones who required assistance with eating, that staff try to serve everyone at the same time, and that residents should not have to sit and watch another resident eat. The facility policy stated meals should be served with dignity and that staff will promote resident independence and dignity in the dining room.
Failure to Serve Full Portions of Altered Diet Menus
Penalty
Summary
The facility failed to follow the menu and serve the complete serving size of altered diet textures for 5 of 5 residents reviewed for serving sizes in a sample of 40. Surveyors observed that the diet spreadsheet for day 9 lunch listed full portions for pureed country fried steak, mashed potatoes with thick gravy, pureed seasoned pasta, pureed buttered soft bread, and pureed mandarin oranges for the pureed diet, and separate full portions for the dental soft diet. The diet spreadsheet for day 12 lunch similarly listed full portions for pureed panko mustard chicken, pureed scalloped potatoes, pureed pickled beets, pureed buttered bread, and pureed peach parfait, with separate full portions for the dental soft diet. R34 had diagnoses including bronchopneumonia, Alzheimer's disease, peripheral vascular disease, and severe protein calorie malnutrition, and had an active order for a regular diet with pureed texture, regular liquid consistency, fortified pudding at lunch and supper, whole milk with meals, and ice cream at lunch and supper. On 05/18/26 at approximately 12:20 PM, R34 received approximately 0.5 of a #8 scoop of pureed country fried steak, and on 05/21/26 at approximately 12:22 PM, received approximately 0.66 of a #6 scoop of pureed panko mustard chicken. R64, with diagnoses including GERD and a history of TIA and cerebral infarction, had an active order for a regular diet with pureed texture and regular liquid consistency, and received approximately 0.5 of a #8 scoop of pureed country fried steak and mashed potatoes on 05/18/26, and approximately 0.66 of a #6 scoop of pureed panko mustard chicken and approximately 0.66 of a #8 scoop of pureed scalloped potatoes on 05/21/26. R87 had diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage, aphasia, dementia, abnormal weight loss, and dysphagia, and had an active order for a regular diet with pureed texture, regular liquid consistency, 2x protein at breakfast, and whole milk in place of menu milk. On 05/18/26, R87 received approximately 0.5 of a #8 scoop of pureed country fried steak and mashed potatoes, and on 05/21/26 received approximately 0.66 of a #6 scoop of pureed panko mustard chicken and approximately 0.66 of a #8 scoop of pureed scalloped potatoes. R9 and R18, both ordered mechanical soft diets, also received approximately 0.5 of a #8 scoop of ground country fried steak and mashed potatoes on 05/18/26 and approximately 0.66 of a #8 scoop of ground panko mustard chicken and scalloped potatoes on 05/21/26. On 05/21/26 at 3:10 PM, the Administrator stated the menu should be followed and full scoops of the mechanically altered diets should be served.
Failure to Provide Access to Personal Property After Room Change
Penalty
Summary
The facility failed to provide a resident access to personal property after the resident was moved to a different room following an altercation with a roommate. The resident was admitted on 6/27/2025 with diagnoses including type 2 diabetes mellitus, muscle weakness, dysphagia, and venous insufficiency, and the MDS dated 3/13/26 documented a BIMS score of 15/15, indicating the resident was cognitively intact. The same MDS documented bilateral leg impairment, wheelchair use for locomotion, dependence on staff for toileting, and substantial to maximum assistance needed for showers and dressing. The resident stated that about a week before the interview, he was moved to a new room on a different hall because he and his roommate got into a fight, but his belongings were not moved with him and he had been without access to them for over a week. The resident said he had asked staff every day to bring his belongings to his new room. The medical record documented the altercation and temporary room move on 5/11/2026. Housekeeping staff confirmed the resident had moved to a different hall and that his belongings were still in the old room; one housekeeper said she would move them later, while another stated belongings should have been moved the same day and that this is usually how it is done. The resident's belongings were observed still in the old room before later being observed in the new room. The facility's admission contract states residents have the right to keep and use their own property and to have a safe place for small valuables that can be accessed daily.
Failure to Implement Documented Fall Intervention
Penalty
Summary
The facility failed to implement a documented fall intervention for one resident, R81, who was admitted with diagnoses including dementia, Alzheimer's disease, repeated falls, insomnia, and polyneuropathy. Her MDS documented a BIMS score of 99, indicating she was unable to answer questions due to poor cognition, and also noted that she required a walker for ambulation, supervision and/or touch assist for transfers, and had a history of falls. Her fall risk assessment documented a score of 14, showing she remained at risk for falls. R81's care plan included a focus area for increased risk of falls with an intervention for an assist bar added to the left side of her bed to assist with balance before standing. During observation, R81's bed had no assist bar on either side, and the Memory Care Director verified that none was present. The surveyor and the Memory Care Director reviewed the electronic care plan and confirmed that the assist bar was listed as a fall intervention. Later, an assist bar was observed attached to the bed frame. Staff and the Administrator stated they would expect the assist bar to be in place if it was ordered or implemented as a fall precaution, and the facility's fall policy states staff will identify and implement interventions related to the resident's specific risks and causes to prevent falls and minimize complications.
Failure to Maintain AED and Crash Cart Supplies for CPR
Penalty
Summary
The deficiency involves the facility’s failure to maintain essential emergency equipment on the crash cart, specifically the automated external defibrillator (AED), while it was present and expected to be available for use during cardiopulmonary resuscitation (CPR). One resident with multiple serious cardiopulmonary and systemic diagnoses, including acute and chronic respiratory failure with hypercapnia and hypoxia, pulmonary hypertension, obstructive sleep apnea, and chronic kidney disease, had a POLST form indicating full code status with orders to attempt CPR and use all indicated life-sustaining treatments, including intubation and mechanical ventilation. The resident was cognitively intact per a BIMS score of 15 and dependent on staff for activities of daily living. On the day of the event, a physical therapist notified an LPN that the resident was unresponsive. The LPN entered the room, found the resident not breathing and without a pulse, and initiated CPR while 911 was called. Another LPN retrieved the crash cart, provided an Ambu bag to staff, and attempted to use the AED. When she opened the crash cart and the AED, she could not locate any AED pads on the cart and the AED repeatedly announced “low battery.” She reported that she ultimately closed the AED because there were no pads and the device was indicating a low battery, and she felt she had wasted time searching for pads and trying to hook up the AED. EMS arrived and the resident was later pronounced dead. Interviews and record review showed that the facility had only one crash cart, and the ADON stated she was responsible for checking it monthly. The crash cart checklist did not include the AED, and there was no documentation that the AED was being checked as part of the crash cart inventory. The ADON stated that for approximately four months the AED had repeatedly given a “low battery” voice prompt when opened, and that she had informed the facility owner, who stated they did not need a new battery at that time. Staff reported that the last set of AED pads had been used during a prior code and that this had been reported to the ADON, but no replacement pads were available when the resident coded. The administrator acknowledged he had known about the low battery for some time and that ordering a battery and pads required an approval process, and invoices and supplier confirmations showed that the battery and pads were not ordered until after the later code event. Additional interviews revealed that the regional director of operations was unaware an AED was in the facility and did not see a problem because he believed an AED was not required by regulation until a future year. The DON confirmed awareness that the AED on the crash cart had a low battery for at least a couple of months and that the last set of pads had been used in a prior code, leaving no adult pads available for the subsequent code. The facility owner stated he was aware of the low battery and asserted that the AED was still functioning, and he also stated that the nurses did not need to use the AED on the last code. Observation of the AED with the administrator present showed the device flashing red lights and repeatedly announcing “low battery” when opened. The AED manufacturer’s manual specified daily and monthly maintenance, including checking that the status indicator is green and replacing the battery when the indicator is red and flashing. Facility policies required that the emergency cart be inventoried and restocked after each use, checked at least monthly with documentation, and that equipment and supplies necessary for CPR/BLS be maintained in the facility at all times. At the time of the survey, 32 residents in the facility had active orders to attempt resuscitation/CPR.
Failure to Timely Transmit MDS Discharge Assessments
Penalty
Summary
The facility failed to timely transmit Minimum Data Set (MDS) assessments for two residents who were reviewed for timely MDS submission. One resident, with diagnoses including Chronic Obstructive Pulmonary Disease, anxiety, and depression, had an admission MDS assessment completed but did not have a required discharge assessment transmitted by the due date. Similarly, another resident with a history of repeated falls, anemia, type 2 diabetes, and muscle weakness also had only an admission MDS assessment completed, with the discharge assessment not transmitted by the required deadline. The MDS Coordinator acknowledged that the quarterly assessments for both residents were overdue and confirmed that discharge assessments should have been completed and transmitted by their respective due dates. Validation reports confirmed that both discharge assessments were transmitted several months after their target dates, with completion dates more than 14 days past the assessment reference dates.
Medication Administration Error Involving Two Residents
Penalty
Summary
Two residents with severe cognitive impairment were involved in a significant medication error when a registered nurse, while administering medications, became distracted by a conflict in the hallway. The nurse accidentally mixed up unlabeled medication cups and administered the wrong medications to each resident. One resident, with diagnoses including unspecified dementia, psychotic disturbance, anxiety disorder, and atrial fibrillation, received another resident's medications, which included donepezil. The other resident, also with severe cognitive impairment and diagnoses of dementia, psychotic disturbance, altered mental status, and muscle weakness, received medications intended for the first resident, including acetaminophen, valproate, and apixaban. The incident was documented in the residents' progress notes, with the nurse acknowledging the error and specifying the medications that were incorrectly administered. The facility's policy defines a medication error as the preparation or administration of drugs not in accordance with physician's orders, manufacturer specifications, or accepted professional standards. The error was identified and reported to facility leadership, and the event was investigated as a significant medication error involving two residents during a medication pass.
Improper Transfer of Resident Without Mechanical Lift
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, leading to an accident hazard. The resident, who has severe cognitive impairment and multiple medical conditions including cerebral aneurysm, contractures, and atrial fibrillation, was dependent on staff for transfers and required the use of a mechanical lift with two-person assistance. Despite these documented needs, two CNAs transferred the resident without using the mechanical lift, lifting her under the arms instead. The incident occurred when the CNAs, who were not familiar with the resident's care requirements, transferred her to the shower without consulting the kardex or being aware of the need for a mechanical lift. The resident sustained a large bruise on her right forearm, which was noticed the following day. The CNAs reported that the resident did not scream or indicate distress during the transfer, and they were unaware of the need for a mechanical lift. The facility's policy on safe lifting and movement of residents mandates the use of mechanical lifting devices for residents requiring such assistance. However, the CNAs did not adhere to this policy, resulting in the resident being transferred improperly. The incident was reported to the administration, and the resident's physician and power of attorney were notified. The resident expressed dissatisfaction with the CNAs involved and refused to allow them to assist her again.
Significant Medication Error Due to Incorrect Order Entry
Penalty
Summary
The facility failed to ensure medications were administered as ordered for one resident, resulting in a significant medication error. The resident, who had diagnoses including Alzheimer's Disease, Essential Hypertension, and Dementia, was prescribed Zaroxolyn for five days. However, due to an error in the Electronic Medical Record (EMR) system, the medication was administered for ten days instead of the prescribed five days. This error led to the resident experiencing dizziness, abnormal lab values, and eventually an Acute Kidney Injury, necessitating hospital admission for treatment with intravenous fluids and supplemental potassium medication. The error was discovered when the resident began showing symptoms of dizziness and decreased urination. Upon review, it was found that the order for Zaroxolyn had been entered into the EMR system with an indefinite end date, causing the medication to be administered beyond the intended period. The resident's condition deteriorated, showing high blood urea nitrogen (BUN) and creatinine levels, low sodium and potassium levels, and a low glomerular filtration rate (GFR). Despite attempts to manage the resident's condition with intravenous fluids and adjusted medication dosages, the resident continued to remove the IV line, complicating treatment. The incident was reported to the Director of Nursing (DON) and the attending physician, who confirmed that the extended administration of Zaroxolyn was a medication error. The error was attributed to the Licensed Practical Nurse (LPN) who entered the order without specifying an end date. The facility's policy on administering medications was not followed, leading to the resident's hospitalization and subsequent treatment for Acute Kidney Injury. The deficiency highlights a critical lapse in medication administration and order entry protocols within the facility.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Carmi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White County Rehab And Nursing | 0.3 mi | ★★★★★ | 2 | 0 |
| Premier Healthcare Of New Harmony | 14.2 mi | ★★★★★ | 28 | 0 |
| The Haven On The River | 15.2 mi | ★★★★★ | 13 | 1 |
| Mount Vernon Nursing And Rehabilitation | 17.6 mi | ★★★★★ | 3 | 0 |
| Mcleansboro Rehab & Hlth C Ctr | 20.1 mi | ★★★★★ | 0 | 0 |
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