Wabasso Restorative Care Center

In the surveyor’s words

From the most serious findings on record at Wabasso Restorative Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF740Jul 8, 2026

  Based on observation, interview, and record review the facility failed to implement appropriate interventions and supervision, monitor and assess changes in mood and mental status, coordinate care with psychiatric providers, and notify the providers of changes in mood/behavior for 1 of 3 residents (R1) who had a significant history of suicidal ideation and suicide attempts. These failures resulted in Immediate Jeopardy (IJ) when R1 attempted suicide after a progressive decline in mood and behavior following the discontinuation of two psychotropic medications without increased monitoring, provider notification, or revision of interventions. […]

• Immediate jeopardy, isolatedF600May 28, 2025

  Based on interview, observation and document review, the facility failed to ensure adequate supervision and a comprehensive assessment was completed to help prevent resident to resident sexual abuse. As a result of the facilities failures an immediate jeopardy (IJ) situation was identified when resident (R2) wrote unwanted paper notes that were sexual in nature and hand delivered them to R1, resulting in psychosocial harm related to triggering symptoms of PTSD (Post-Traumatic stress disorder) derived from childhood sexual abuse and feelings of insecurity for 1 of 2 residents (R1) reviewed for abuse. The IJ began on 3/27/25 when three residents reported inappropriate behavior by R2, including writing notes that were sexual in natural and touching residents. […]

• Immediate jeopardy, isolatedF686Jul 12, 2023

  Based on observation, interview, and document review the facility failed to complete comprehensive pressure ulcer assessments and ensure physician ordered wound vac therapy was adequately managed for 2 of 3 residents (R1, R3) who required wound vac therapy. The facility's failures resulted in an immediate jeopardy (IJ) for R1's when their pressure ulcer deteriorated resulting in necrosis, bone exposure and hospitalization . The immediate jeopardy began on 6/26/23, when wound clinic identified R1's wound had deteriorated to the bone from improper dressing placement and mismanagement of the wound vac. The IJ was identified on 7/10/23 and the administrator, assistant administrator, and director of nursing (DON) were notified of the IJ on 7/10/23 at 5:45 p.m. […]

• Actual harm, isolatedF689May 20, 2026

  Based on observation, interview, and document review the facility failed to ensure alcohol sanitizing clothes were stored safely out of reach for 1 of 1 resident (R1). The facility's failures resulted in harm for R1 after she obtained alcohol sanitizing/germicidal wipes, placed them in a glass with water, ingested the solution, and required hospitalization with a resulting diagnosis that included acute kidney injury. Findings include: R1's face sheet dated 5/20/26, identified diagnoses of alcohol abuse, attention deficit hyperactivity disorder, major depressive disorder, and seizures. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, had no behaviors or rejection of care, was independent with transfers and mobility with the use of a walker. […]

• Actual harm, isolatedF689Feb 25, 2026

  Based on observation, interview and document review the facility failed to ensure 1 of 3 residents were free from avoidable accidents from hot liquids. This resulted in actual harm to R1 who spilled hot coffee on her lap and sustained a third-degree burn. In addition, the facility failed to implement a system to assess residents for safety with hot liquids. The facility implemented appropriate corrective action prior to the onsite investigation; therefore, the deficiency is being cited at past non-compliance.Findings include:A Vulnerable Adult Maltreatment Report submitted to the State Agency on 2/19/26, identified R1 was transferred to the emergency room (ER) related to fever and lethargy. R1 was noted to have a severe burn that was covering a large portion of the thigh with peeling skin. […]