Inspection·January 14, 2026

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unlocked it and grabbed the Ambu bag (bag valve mask) and gave it to one of the other staff members in the room and she grabbed the AED machine. V11 stated she started searching for pads and could not find any pads anywhere on the cart, V11 stated she opened the AED machine, and it automatically turns on, the AED started saying low battery, low battery. V11 stated she finally closed the door on the AED because she could not do anything without the pads and the machine was still saying low battery. V11 stated EMS arrived and time of death was called at 4:47PM. V11 stated she has had training on AED's through her CPR class. V11 stated she was taught in CPR training that if you have an AED available to use it and that is what she tried to do. V11 stated she notified V2 (Director of Nursing/DON) immediately and told her there were no pads and it was saying low battery. V11 stated another nurse, V12 (Registered Nurse/RN), told her she had used the last set of pads on a code on [DATE] and had reported it to V6 (Assistant Director of Nursing/ADON) that there were no more pads. V11 stated she felt like she wasted time looking for pads and trying to get R1 hooked to the AED.On [DATE] at 10:04AM, V6 stated there is only one crash cart for the whole facility. V6 stated she is in charge of checking the crash cart monthly. V6 stated they did have an AED (Automated External Defibrillator) on the crash cart, but it has been removed recently as of Monday [DATE]. V6 stated the last time the AED was used, it did work she thinks but the battery was low. V6 stated V1 (Administrator) is in charge of ordering new pads for the AED. V6 stated the AED is in the administrator's office at this time until they get a new battery. V6 was asked if there is a check list of the items checked on the crash cart and V6 provided a document titled Crash Cart Checklist. The list did not include a check for an AED machine. The last documented check was on [DATE]. V3 stated the cart must be checked monthly. V6 stated she was not aware of the AED not being used while the AED was present on the cart. V6 stated all the staff get training about every 6 months on CPR and includes the use of an AED. On [DATE] at 1:07PM, V6 stated when she checked the crash cart monthly, she stated she would turn on the AED machine every time. V6 stated battery low would display every time for the last 4 months (since [DATE]). V6 stated we talked to (V13 Facility Owner) and he stated we didn't need one (battery) but he did just finally approve the purchase of a battery I believe. V6 said the pads to the AED were used on the last code on [DATE] and she believes pads have been ordered. V6 stated she also would check for pads when she checked the AED, and she said there were always 2 sets of pads on the cart. V6 stated the pads were used when they had codes in between the monthly checks evidently so there were no pads when the last resident coded on [DATE]. V6 stated the nursing staff have all been CPR trained and this includes the use of an AED.On [DATE] at 11:24AM, V1 (Administrator) was asked if he receives work orders from maintenance or whoever orders supplies for equipment. V1 stated he does receive request for supplies that need to be ordered. V1 was asked if he was notified that the battery was low on the AED machine, V1 stated yes, he has known for a while and has sent up request and it is a process we have to go through to get approvals for items that need to be ordered. V1 stated I believe we have permission now. V1 was asked if the battery and the pads have been ordered yet and he stated no, not yet. V1 stated the AED machine has been pulled from the crash cart and is in his office until the battery and pads have been ordered and received and at that time the AED machine will be returned to the crash cart.On [DATE] at 12:08PM, V8 (Regional Director of Operations) stated he was unaware that there was an AED in the facility, and it must have been in the facility when the company bought the facility. V8 stated it is not a regulation to have an AED until 2030 and he doesn't see the problem. V8 was informed that the AED had been present on the crash cart but not checked or maintained.On [DATE] at 12:34PM, V2 (Director of Nursing) stated she was aware that there was an AED on the crash cart. V2 stated V6 checks the crash cart monthly and includes AED checks. V2 stated they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146019 If continuation sheet Page 2 of 4 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 01/14/2026 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had known the battery was low for a while but thought that it still functioned even though it said low battery. V2 stated the AED was used on another resident in December but showed a non-shockable rhythm. V2 stated I guess that is when the last set of pads were used because when they had another resident to code on [DATE], there were no adult pads available, and the battery was low. V2 stated the nurses are expected to use the AED machine when it is available. V2 stated the battery has been low for a couple of months and that is as far back as she knows because she has only worked here a couple of months. V2 stated she does not have documentation to prove the AED was checked monthly as it is not on the crash cart checklist. V2 stated the supplies are ordered by Medical Records/supplies personnel.On [DATE] at 9:12AM spoke with V6 in regard to checking of the AED. V6 stated she checked it monthly, and she would open it up and make sure it came on and then closed it. V6 stated she does not remember any lights on the machine she just remembers that it would voice prompt low battery. V6 stated she would then close it back down. On [DATE] at 10:15AM, V13 (Facility Owner) stated he was aware that the battery was low on the AED machine. V13 stated the AED was still functioning even with a low battery. V13 stated they (nurses) didn't need to use the AED on R1 the last code. When V13 was asked to clarify, V13 replied she was dead and they started CPR, they continued CPR until the EMS arrived and they then called the code. V13 stated you know when someone is really dead, and you still have to do CPR. V13 stated as soon as the facility was made aware that they were out of pads, the pads were ordered for the AED machine. V13 was asked if he expected the staff to keep documentation of the checks on the AED machine and V13 stated I refuse to answer that question. On [DATE] at 12:25PM, the AED machine was observed with V1 present. The AED Machine was opened up and automatically was flashing red lights and had an activated voice prompt of Low Battery, Low Battery repeatedly for 35 seconds. On [DATE] at 3:00PM, V15 (Regional Community Liaison) provided the invoices for the AED battery and pads. The invoice documents that Adult Pads were ordered on [DATE], with order confirmation date of [DATE]. The invoice for the AED battery documents the order was placed on [DATE].On [DATE] at 2:14PM, V17 (Sales Representative) with the medical supply company that the order for the AED pads were placed, confirmed the order number documented on the invoice provided by V15 and stated that the order date was [DATE] and not [DATE] as documented on the invoice provided by V15. V17 provided the invoice with the documented order date of [DATE].On [DATE] at 1:50PM, V16 (Sales Representative) with the medical supply company that the AED battery was placed, confirmed the order number of the invoice provided by V15 and stated that the order was placed late on [DATE] and that there were no other orders placed by this the facility for an AED battery before [DATE]. V16 stated their invoice documents and order date of [DATE] because order was placed late in the evening, so date fell to the next business day. V16 provided this invoice with the order date of [DATE].The Owners Manual for the AED documents under the section titles Schedule Maintenance documents daily maintenance: Check the Status Indicator to ensure that it is green. When the light is Green, the AED is ready for rescue. If the indicator is RED, refer to troubleshooting table on page 5-3. Indicator troubleshooting table documents for battery: the last battery indicator (LED) is red and flashing. Solution: The battery is low. Replace with a new battery. Monthly maintenance: Open the AED lid, wait for the AED to indicate status. Observe the change of the status indicator or RED. After 5 seconds, verify that the Status Indicator returns to GREEN. Check that the battery has adequate charge. If the battery indicator is red, replace the battery.The facility policy titled Policy for Emergency Cart (E-Cart) with a revision date of [DATE] documents Purpose: To organize and maintain the emergency cart (E-Cart) to ensure adequate needed equipment for CPR procedures. Under the section titled Policy documents The E-Cart will be inventoried and restocked after each use and checked at least monthly and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146019 If continuation sheet Page 3 of 4 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 01/14/2026 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 0908 Level of Harm - Minimal harm or potential for actual harm documented.The facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation with a revision date of February 2018 documents under Preparation for Cardiopulmonary Resuscitation 2. Maintain equipment and supplies necessary for CPR/BLS (Basic Life Support) in the facility at all times.An Order Listing Report dated [DATE] documents active orders for life sustaining treatment or all residents residing in the facility. There are 32 residents (R4-R36) on this report with active orders to attempt resuscitation/CPR. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146019 If continuation sheet Page 4 of 4