Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellbrooke Of Crawfordsville during CMS and state inspections, most recent first.
A resident with Parkinson’s disease had a living will stating she did not want life-prolonging treatment, but her record was changed to full code on admission. The DON stated residents were admitted as full code unless they had a signed physician order such as an OOH or POST, and said she was not aware the resident had a living will because the clinical team did not receive living wills in the admission packet.
A resident with aphasia, dysphagia, Parkinson’s disease, muscle weakness, and a history of falls had a DNR order, but the comprehensive care plan listed full code status. The DON provided the full code care plan during survey, and the facility policy stated the comprehensive care plan is to be developed within 7 days of the comprehensive assessment.
A resident with aphasia, dysphagia, SVT, muscle weakness, and a history of falls had an order for metoprolol tartrate to be held if SBP was below 100 or pulse was below 60. The medication was administered on two occasions even though the resident’s BP readings were below the ordered hold parameters, and the DON confirmed it was given outside the ordered limits.
Failure to follow fall and transfer interventions for a resident with dementia, hemiplegia/hemiparesis s/p CVA, and anxiety. After repeated bathroom falls, staff were instructed not to leave the resident unattended in the bathroom, yet she was later left alone in the bathroom on multiple occasions and was found on the floor with no staff present. After a transfer-related fall, the resident was to be a 2-person assist for transfers, but she was later transferred by only one aide on several occasions and was lowered to the floor each time.
Failure to maintain nutritional and pharmaceutical supplements for a resident with dementia, malnourishment, and adult failure to thrive led to continued weight loss and repeated low weights. The resident had poor PO intake, fluctuating weights, and multiple nutrition interventions including Ensure, MedPass, fortified foods, an ice cream and cranberry juice shake, and Mirtazapine. Ensure and Mirtazapine were discontinued while the resident was still underweight and trending down, and the resident continued to have significant weight loss and weights under 80 lbs before Mirtazapine was later restarted.
Failure to Provide Individualized Dementia Care and Meaningful Engagement: A resident with dementia and anxiety was repeatedly observed seated in a locked Broda chair at the nurses’ station, slouched or leaning to one side, while pulling off clothing, exposing her breasts, fidgeting, and showing signs of restlessness and discomfort. Staff briefly replaced clothing at times but did not provide meaningful redirection, assessment, or individualized interventions, and the resident was not consistently offered preferred activities such as Bible study, pet therapy, sensory items, or other calming engagement documented in her care plan and activity records.
The facility failed to ensure proper handwashing practices during dining observations, affecting all residents who ate meals from the kitchen. Staff members were observed washing hands inadequately, either for less than 20 seconds or without using paper towels to turn off faucets, before serving food to residents. This was contrary to the facility's hand hygiene policy, as confirmed by interviews with staff.
The facility did not ensure that resolutions to concerns raised by the Resident Council were communicated back to them. A resident reported that department managers did not attend meetings to discuss grievances. Meeting minutes showed unresolved issues in nursing, maintenance, and dietary departments. The Activity Director documented concerns but rarely received responses, and the Executive Director confirmed that resolutions were not communicated back to the council as per policy.
The facility failed to conduct quarterly care plan meetings for three residents, leading to a deficiency in care planning. A resident's family member and two residents reported not recalling recent meetings, and records confirmed missing documentation for required meetings. Facility staff were aware of the backlog and had initiated an audit action plan to address the issue.
A resident with dementia and dysphasia experienced a significant weight loss of 9.3% over 30 days, which the facility failed to address. Despite care plans indicating the resident was at risk for malnutrition, the weight loss was not documented or acted upon. Staff interviews revealed discrepancies in intake records and dietician assessments, and the facility's weight tracking policy was not followed.
A facility failed to properly label medications on a medication cart, with undated and opened insulin medications found for two residents. An insulin pen with an incomplete label was also discovered, lacking essential information. Interviews revealed that the medications should have been dated when opened, but the facility's policy was not followed.
Advance Directive Not Honored on Admission
Penalty
Summary
The facility failed to ensure a resident’s predetermined advance directive preference of Do Not Resuscitate (DNR) was honored when she was changed to full code status on admission. The resident had diagnoses including Parkinson’s disease, and her record contained a living will dated 2/27/1992 stating that she did not want her life artificially prolonged and directing that life-prolonging procedures be withheld or withdrawn if she had an incurable injury, disease, or illness certified as terminal by her attending physician. The living will was scanned into the record on 11/17/25. Despite the living will, a comprehensive care plan initiated on 11/18/25 indicated the resident desired to be full code, and a physician’s order for full code was added to the record on 11/17/25. During interview, the DNS stated all residents were admitted as full code unless they had a signed physician’s order such as an OOH or POST, and said she was not aware the resident had a living will. She also stated the clinical team did not get living wills in the admission packets and received them from the family at the time of admission.
Code Status Did Not Match Care Plan
Penalty
Summary
The facility failed to ensure that Resident 12’s code status matched the comprehensive care plan. Record review showed the resident had diagnoses including aphasia, dysphagia, cystitis, Parkinson’s disease, muscle weakness, and a history of falling. The resident had a physician’s order for DNR dated 7/22/25, but the comprehensive care plan dated 7/16/25 indicated a full code status. During the survey, the Director of Nursing Services provided a copy of the full code care plan, and the facility policy titled Comprehensive Care Plan Guideline stated that a comprehensive care plan will be developed within 7 days of completion of the comprehensive assessment (MDS 3.0).
Medication Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure a medication was withheld according to the physician-ordered parameters for Resident 12. The resident had diagnoses including aphasia, dysphagia, supraventricular tachycardia, muscle weakness, and a history of falling. She had an order for metoprolol tartrate 25 mg, one-half tablet by mouth twice daily, with instructions to hold the medication for systolic blood pressure less than 100 or pulse less than 60. The record showed metoprolol was administered on 11/11/25 when the blood pressure was 99/61 and on 10/18/25 when the blood pressure was 98/62. The Director of Nursing Services stated on 11/20/25 that the medication was given outside of the ordered parameters.
Failure to Follow Fall and Transfer Interventions
Penalty
Summary
The facility failed to ensure a resident’s fall interventions were followed after repeated bathroom falls and transfer-related incidents. The resident had diagnoses including dementia, hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, and anxiety. From 1/1/25 through 4/17/25, she had three falls in the bathroom, including a witnessed fall on 3/8/25 and 3/16/25, and an unwitnessed fall on 3/29/25 that caused a skin tear. After the 4/17/25 fall, an IDT note on 4/18/25 stated the new intervention was for staff not to leave her unattended in the bathroom. Despite that intervention, she was left alone in the bathroom on three later occasions: on 6/2/25 she was upset that an aide did not return while she was in the bathroom, on 6/13/25 she was left alone in the bathroom while requesting assistance back to her chair, and on 8/21/25 she was found on the floor after being assisted to the toilet with no staff present. The resident was also lowered to the floor eight times between 2/4/25 and 7/22/25. After a 5/14/25 witnessed transfer fall, the new intervention was for her to be a 2-person assist with transfers until therapy could assess safe transfers, but on 6/18/25, 6/25/25, and 7/22/25 she was transferred by only one aide and was lowered to the floor each time. The DON stated the resident was impulsive and often transferred without staff knowledge, and that when new interventions were placed it was her expectation that all staff implement them as listed on the resident’s Care Profile.
Failure to Maintain Nutritional and Pharmaceutical Supplements for a Resident with Ongoing Weight Loss
Penalty
Summary
The facility failed to continue nutritional and pharmaceutical supplements for a resident with dementia, malnourishment, and adult failure to thrive who was not yet at her goal weight. Resident 46 was admitted with a mechanical soft diet and weekly weights ordered. Her admission nutrition assessment documented a BMI of 20 with a goal BMI of 22 and stable weight, and the dietician recommended Ensure daily with an increase to twice daily if intake was good. Over time, the resident had repeated weight loss and fluctuating intake, with multiple nutrition assessments and care notes documenting poor meal consumption and ongoing weight decline. The resident’s weight dropped from the low 100-pound range to 94 pounds in early December, then to 84.4 pounds in February, with nutrition notes describing significant losses over 30 and 90 days. Additional interventions were added, including Mirtazapine, fortified foods, Ensure three times daily, MedPass, and an ice cream and cranberry juice shake at meals. Despite these measures, the resident continued to lose weight, with weights recorded as low as 77.6 pounds in April, 77 pounds in September, and 76.8 pounds in November. The record also showed periods when weekly weights were discontinued and monthly weights resumed even while the resident remained underweight and losing weight. The report also shows that nutritional and pharmaceutical supplements were discontinued while the resident was still not at goal and continued to trend downward. Ensure three times daily was discontinued in June, and Mirtazapine 15 milligrams daily was discontinued in July. After those changes, the resident had multiple weights under 80 pounds before Mirtazapine was restarted in November. Staff observations in November described the resident as restless, uninterested in eating, and eating very little in the dining room. Interviews with the NP, psych NP, and RD Director reflected awareness of the resident’s weight loss and poor intake, but the resident continued to have significant weight fluctuations and ongoing low weights during the period when supplements and medication had been stopped.
Failure to Provide Individualized Dementia Care and Meaningful Engagement
Penalty
Summary
The facility failed to provide effective individualized person-centered care for a resident with diagnoses including unspecified dementia, adult failure to thrive, and anxiety, who exhibited repeated dementia-related behaviors such as pulling off clothing, restlessness, fidgeting, and signs of discomfort. During multiple continuous observations, the resident was seated in a reclined Broda wheelchair locked in place at a common table near the nurses’ station, often slouched or leaning to one side, while staff, residents, and visitors passed through the area and could observe her. She repeatedly attempted to undress, pulled her shirt over her head exposing her breasts, pulled at her pants legs, removed her socks, and fidgeted with her blanket and clothing. Staff were observed briefly replacing clothing at times, but no meaningful redirection, assessment, or individualized intervention was observed during these episodes. The resident also displayed ongoing restlessness and discomfort, including sitting up and leaning forward, sighing deeply, grunting, wiggling in her chair, pulling her legs up to her chest, scratching the back of her head, and making undirected speech such as “what is this? I don’t know. What now?” On one observation, she was taken to a volunteer-led Bible study and briefly visited 1:1 with an activity aide, but she was later returned to the common area nurses’ station. A therapy pet dog came to the nurses’ station, but staff did not ensure the resident had a visit with the pet. The resident was repeatedly left at the nurses’ station with only a blanket, and items available in the area such as folding items, magazines, or a fidget blanket were not offered to her. The resident’s record showed prior documentation of restlessness, anxiety, and behaviors including grabbing at staff, pulling at clothing, stripping clothing in bed, yelling out, and pushing the common area table with her legs. Her care plan identified that her decision-making regarding daily activity engagement may be altered due to dementia and noted preferences including being read to, animal therapy, and Christian religion, with interventions for one-to-one assistance and calming individualized activities. However, the full care plan set lacked implementation and/or revision to address unsafe positioning in the Broda chair, pulling clothes off, and constant fidgeting or scratching. Activity logs also documented participation in sensory basket, Bible study, listening to music, and craft activities, but the survey observations did not match those entries, as the resident was not observed being offered those activities or having music playing at the documented times.
Improper Handwashing Practices Observed in Dining Area
Penalty
Summary
The facility failed to ensure proper handwashing practices during two dining observations, which had the potential to affect all 53 residents who consumed meals from the kitchen. During the first observation, multiple staff members, including a dietary services assistant and an activity associate, were seen washing their hands inadequately. They either washed their hands for less than the recommended 20 seconds or failed to use a paper towel to turn off the faucet, instead using their bare hands. This improper technique was observed as they returned to the kitchen and served food to residents, potentially compromising food safety. In the second observation, similar handwashing deficiencies were noted. Staff members continued to wash their hands for insufficient durations and touched faucet handles with bare hands, contrary to the facility's hand hygiene policy. Interviews with a Certified Residential Medication Aide and a Registered Nurse confirmed that staff were expected to use paper towels to turn off faucets to prevent recontamination. The Director of Nursing provided the facility's hand hygiene policy, which outlined the correct procedure, indicating a failure in adherence to established guidelines.
Failure to Communicate Resolutions to Resident Council
Penalty
Summary
The facility failed to ensure that resolutions to concerns voiced by the Resident Council were communicated back to the council. During an interview, a resident indicated that department managers or other staff members had not attended Resident Council meetings to discuss grievances. The review of the Resident Council Meeting Minutes revealed that concerns related to nursing, maintenance, and dietary departments lacked documented responses from the respective departments. The Activity Director stated that she documented the Resident Council's concerns and placed them in the mailboxes of the appropriate department directors, but rarely received responses. The Executive Director confirmed that staff would only attend Resident Council meetings if invited and that grievances were documented and forwarded to department directors for resolution. However, the resolutions were not communicated back to the Resident Council as required by the facility's policy.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings at least quarterly for three residents, leading to a deficiency in care planning. Resident 34's daughter-in-law reported not recalling any quarterly care plan meetings over the past year. The resident's records confirmed a lack of documentation for meetings between July 2023 and May 2024, despite the resident having severe cognitive deficits. Similarly, Resident 23, who was cognitively intact, could not remember attending a recent care plan meeting, and records showed no meetings between August 2023 and May 2024. Resident 1, also cognitively intact, reported not being invited to recent meetings, with records lacking documentation of meetings from July 2023 to May 2024. Interviews with facility staff revealed awareness of the backlog in conducting quarterly care plan meetings. The Social Service Director, hired in November 2023, acknowledged the delay and was working to catch up. The Regional MDS Support confirmed the facility identified the issue in January 2024 and initiated an audit action plan, which was still ongoing. The Director of Nursing provided a policy document indicating that meetings should occur quarterly, highlighting the facility's failure to adhere to its guidelines.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss in a resident, identified as Resident 34, who experienced a weight loss of 9.3% over a 30-day period. The resident's medical history included unspecified dementia and dysphasia, which required supervision with eating. Despite a care plan indicating the resident was at risk for malnutrition and had impaired swallowing, the facility did not document or act upon the weight loss when it occurred. The resident's weight dropped from 129.8 pounds to 121 pounds between May 5 and June 5, 2024, but there was no documentation of this weight loss being identified or addressed in the resident's records. Interviews with facility staff revealed uncertainty about why the weight loss was not addressed, with discrepancies noted between actual intake records and dietician assessments. The facility's policy required notification of significant weight variances, but this was not followed in the case of Resident 34. The facility's guidelines for weight tracking were not adhered to, as the resident's significant weight loss was not documented or acted upon in a timely manner, leading to a deficiency in the care provided to the resident.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling of medications for one of the two medication carts observed during a survey. During an observation, it was found that the 200-hall medication cart contained undated and opened insulin medications labeled for specific residents. Specifically, a Humalog insulin for one resident and a Lantus insulin for another were found without dates indicating when they were opened. Additionally, a Lantus insulin pen was found with an incomplete label, missing the resident's full name, room number, and date of opening, with only a handwritten first name present. Interviews with the LPN and DON revealed that the insulins should have been dated when opened, and the incomplete label on the insulin pen was due to it being pulled from the MedBank tower. However, there was no record of when it was pulled or opened, and the system did not log the removal of the insulin pen for the third resident. The facility's policy requires medications to be dated when the manufacturer's seal is broken, but this was not adhered to, leading to the deficiency.
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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.
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Nursing homes near Crawfordsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Creek At Crawfordsville | 1.3 mi | ★★★★★ | 5 | 0 |
| Lane House, The | 1.8 mi | ★★★★★ | 3 | 1 |
| Ben Hur Health And Rehabilitation | 3 mi | ★★★★★ | 2 | 0 |
| Majestic Care Of Lafayette | 22.6 mi | ★★★★★ | 4 | 0 |
| Homewood Health Campus | 22.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.