Inspection·April 25, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 apixaban (blood thinner) 5mg tablet-take 1 tablet by mouth twice a day. R83's Progress Note dated 3/17/2025 by V3 (Registered Nurse/RN) documented that she was passing medications and took R83 and R92 back to their shared room. V3 documented that she heard a conflict up the hall that made her accidentally mix up the unlabeled medication cups. V3 documented R83 was given R92's medications including donepezil (dementia treatment) 5mg. 2. R92's admission Record documented an admission date of 8/8/2024 and included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood, altered mental status and muscle weakness. R92's MDS dated [DATE] documented a BIMS score of 3, which indicates severe cognitive impairment. R92's Physician Order Summary documented donepezil hydrochloride (dementia treatment) 5mg-1 tablet by mouth at bedtime and memantine (dementia treatment) 10mg tablet, take 1 tablet by mouth twice a day. R92's Progress Note dated 3/17/2025 by V3 (RN) documented that she was passing medications and took R92 and R83 back to their shared room. V3 documented that she heard a conflict up the hall and accidentally swapped the medication cups. V3 documented R92 was given R83's medications including acetaminophen 1000mg, valproate 500mg and apixaban 5mg. On 04/24/25 at 10:00 AM, V1 (Administrator) stated, he had been notified by V3 (RN) that she administered the wrong medications to R83 and R92. V1 stated, he advised V3 to contact V2 (Director of Nursing/DON) and then he immediately started working on the plan of correction that included education and observation of medication administration by nursing staff. On 04/24/25 at 10:36 AM, V2 (DON) stated, she was notified via phone by V3 (RN) that she had given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146019 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R83 and R92 the wrong medications. V2 stated V5 (Physician) was contacted, vitals were obtained on R83 and R92 with monitoring scheduled for every 2 hours for the next 24 hours. V2 stated V1 immediately started a plan of correction that included education and auditing of the nursing staff being observed during medication administration on 10 residents. The facility policy Adverse Consequences and Medications Error (revised April 2014) documented under Policy The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and mediation-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. Under Policy, 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professionals' standards and principles of the professional(s) providing services. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. Incident Investigation of 2 residents on one wing had received the wrong medication during the bedtime medication pass. 2. Per review of the Interdisciplinary team, it is felt that there is potential for other residents. 3. Staff member had been offered education regarding 5 rights of medication administration. Completed by 4/1/2025. Mediation Administration rate at 0% during survey. 4. All nursing staff to be educated regarding 5 rights of medication administration. Completed by 4/1/2025, Medication Administration rate at 0% during survey. 5. The Administrator/Director of Nursing and/or designee will observe return demonstration of medication on each nurse with 10 residents med passes being observed. V2 completed audits by 4/1/2025 with V1 and V2 in attendance. 6. QAPI (Quality Assurance Performance Improvement) meeting held - any issue identified will be immediately corrected and re-education will be offered and reviewed during QAPI meeting. This was also completed by 4/1/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146019 If continuation sheet Page 3 of 3