Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Wellbrooke Of South Bend during CMS and state inspections, most recent first.
A CNA made a disrespectful comment to a resident, telling her to shut up, in front of a family member. The resident had vascular dementia with behavioral disturbance, disorientation, and a fractured femur neck, with significant cognitive impairment and need for partial to moderate assistance with bed mobility, toileting, and transfers. The allegation was substantiated during the facility investigation.
Guardian Not Informed of Antipsychotic Dose Increase: A resident with schizophrenia and dementia had Haldol increased from 1 mg BID to 2 mg AM and 3 mg HS, but the record lacked documentation that the court-appointed guardian was informed or that guardian consent was obtained for the psychotropic dose change. The DON stated the guardian should have been notified and signed the consent, while the consent form in the record was signed by the resident.
The facility failed to administer a resident's midodrine according to the ordered BP parameters; the MAR showed doses missed when BP was within range and a dose given when BP was above the hold parameter, and the DON stated the nurse had read the order wrong. The facility also failed to follow a physician order for another resident's Tubigrips for edema, as the resident was observed without compression wraps while in bed and later wearing only non-slip socks, despite the treatment record showing the wraps as administered.
A resident with a right heel DTI, Sezary disease, severe protein calorie malnutrition, moderate cognitive deficits, and hospice care did not receive the full ordered wound tx. The Wound Nurse cleansed the wound, applied collagen and Xeroform, and wrapped the heel with Kerlix, but did not apply the ordered skin prep to the surrounding skin.
Fall interventions were not fully care planned or in place for a resident with a history of falls. A resident with significant cognitive impairment, prior falls, and a recent femoral neck fracture was observed leaning out of a wheelchair near the nurse's station until a CNA caught the resident as she slipped out of the chair. No alarm sounded during the event, and a floor mat was found propped against a dresser rather than in use. Staff interviews indicated the resident should have had additional fall interventions, including a mat when sleeping and avoidance of the recliner.
An LPN failed to follow infection control guidance during a medication pass when she poured a resident’s solid meds into her ungloved hands, picked up each pill, and placed them in a medicine cup before administering them. The LPN also discarded spironolactone that was being held because the resident’s BP was below ordered parameters. The DON and Clinical Support Nurse later stated the nurse should have worn gloves if touching the pills.
A resident with severe cognitive impairment and multiple chronic conditions experienced a dislodged urinary catheter, which was replaced by a hospice nurse after facility staff contacted hospice services. However, the responsible party was not notified of this significant change in condition, contrary to facility policy, and there was no documentation of notification in the resident's health record.
A CNA did not follow a resident's fall prevention care plan, leaving a resident with dementia and impaired mobility unsupervised on the edge of the bed. The resident attempted to transfer alone, fell, and sustained acute fractures to both femurs, requiring hospitalization and surgery. The care plan required staff assistance for transfers, but this was not provided, leading to the incident.
Three CNAs did not follow required fall protocols after a resident with hemiplegia and altered mental status was lowered to the floor during a transfer. Instead of waiting for a nurse to assess the resident, the CNAs moved her to bed, contrary to state guidelines. The resident was later found to have sustained a displaced femur fracture and a foot fracture.
The facility failed to ensure a process for residents to file grievances anonymously, affecting all 54 residents. Residents were unaware of how to file grievances anonymously, and the facility's app required staff assistance, compromising anonymity. Interviews with staff confirmed that the grievance process did not support true anonymity, potentially affecting residents' rights.
The facility failed to serve food in a sanitary manner in one dining room, affecting nine residents. Dietary aides were observed touching the eating surface of plates with their thumbs while serving meals. The Director of Food Service confirmed that plates should be handled from the bottom, as per the facility's policy.
A facility failed to provide adequate grooming for a resident who was severely cognitively impaired and required assistance with ADLs. Despite having a care plan that included facial shaving on shower days, the resident was observed with multiple white hairs on her chin over several days. Interviews with staff confirmed that facial shaving should be provided unless the resident preferred facial hair, which was not the case. The facility's policy emphasized the importance of grooming, yet the deficiency was evident through observations and lack of documentation.
A facility failed to coordinate and document hospice care for a resident with diabetes and senile degeneration. Despite a physician's order for hospice admission, the hospice communication book lacked essential documentation such as care plans and medication lists. The DON confirmed the absence of these documents, and it was found that the facility lacked a policy for maintaining hospice communication. A hospice services contract outlined documentation responsibilities, which the facility did not fulfill, resulting in a deficiency.
A facility failed to follow standard precautions during blood glucose testing and insulin administration for a resident. An LPN did not perform hand hygiene before and after taking the resident's blood sugar and prior to administering insulin, despite facility policies requiring hand hygiene before and after direct contact with residents and after glove removal. The LPN acknowledged the oversight during an interview.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s dignity when a CNA made a disrespectful comment to the resident, telling her to shut up, in the presence of the resident’s family member. The incident was reported as an FRI, and the allegation of inappropriate language was substantiated during the facility’s investigation. The resident involved had vascular dementia with behavioral disturbance, disorientation, and a fractured femur neck, and the admission MDS indicated significant cognitive impairment, a history of falls, and a need for partial to moderate assistance with bed mobility, toileting, and transfers. The report states that the family member overheard the CNA’s comment while visiting the resident. The resident was moved to a safe place after the incident, and the CNA was suspended and escorted out of the building pending investigation. The facility later determined the allegation was substantiated and the CNA was terminated and reported to the Nurse Aide Registry.
Guardian Not Informed of Antipsychotic Dose Increase
Penalty
Summary
The facility failed to ensure a resident’s legal guardian was informed of a change in treatment related to psychotropic medication. Resident 7 had diagnoses including schizophrenia and dementia, and the quarterly MDS dated 3/5/26 indicated the resident was cognitively intact. The resident had a guardianship order dated 2/17/21 showing she had been adjudicated an incapacitated person and a guardian had been appointed by the court. She was receiving antipsychotic medication, including Haldol ordered on 10/2/25 at 1 mg daily and 1 mg at bedtime. A physician’s order dated 3/4/26 increased Haldol to 2 mg in the morning and 3 mg at bedtime. A psychotropic medication informed consent observation dated 3/5/26 documented the increased antipsychotic dose, and the consent was signed by the resident. The record did not contain documentation that the legal guardian was informed or that consent was obtained from the guardian when the antipsychotic dose was increased. During interview, the DON stated the guardian should have been notified and signed the consent, and also stated the guardian was aware the resident was taking antipsychotic medications and that both the guardian and resident had agreed to the medication.
Failure to Follow Medication and Compression Wrap Orders
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for a resident with heart failure, hypertension, and orthostatic hypotension. A physician ordered midodrine 10 mg three times daily with instructions to hold for systolic blood pressure greater than 130. Review of the April 2026 MAR showed the medication was not administered when the blood pressure was within the ordered parameters on 4/1/26 at 6:00-8:00 a.m. with BP 102/51 and on 4/1/26 at 12:00-1:00 p.m. with BP 122/74, and on 4/6/26 at 6:00-8:00 a.m. with BP 116/72. The medication was also administered on 4/6/26 at 12:00-1:00 p.m. when the BP was 138/77. The DON stated the nurse had read the order wrong and should have given the medication when the BP was below 130 and held it when the BP was over 130. The facility also failed to follow a physician's order for compression wraps for a resident with chronic kidney disease and localized edema. The resident's care plan directed staff to apply Tubigrips to both lower extremities as ordered, and a physician's order required compression wrap from mid-foot to knee, covering the heel, to be applied in the morning and removed at bedtime. During observation, the resident was found in bed with legs uncovered and no compression wraps or socks on, and the legs appeared swollen. Later the resident was observed in a wheelchair and then in the main lobby wearing non-slip socks on both feet. The April 2026 treatment record showed the Tubigrips were marked as administered on 4/17/26.
Failure to Follow Ordered Pressure Injury Treatment
Penalty
Summary
The facility failed to ensure pressure ulcer treatment was provided as ordered for a resident with a deep tissue injury to the right heel. The resident had diagnoses including Sezary disease and severe protein calorie malnutrition, and the admission MDS indicated moderate cognitive deficits and hospice care. A wound assessment dated 3/26/26 documented the right heel DTI, and a physician's order dated 4/11/26 directed staff to gently cleanse and dry the right heel, apply skin prep to the surrounding wound, apply collagen to the wound bed, cover with Xeroform, and wrap with Kerlix every Monday, Wednesday, and Friday. During observation on 4/15/26, the Wound Nurse cleansed the wound, applied collagen and Xeroform, and wrapped the heel with Kerlix, but did not apply the ordered skin prep to the surrounding skin. In interview, the Wound Nurse stated she did not apply the skin prep as ordered.
Fall interventions were not fully care planned or in place for a resident with a history of falls
Penalty
Summary
The facility failed to ensure fall interventions were care planned for and/or in place for a resident with a history of falls. Resident 34 had diagnoses including vascular dementia with behavioral disturbance, disorientation, and fracture of the femur neck. The admission MDS dated 2/10/26 indicated significant cognitive impairment, a history of falls, and the need for partial to moderate assistance with bed mobility, toileting, and transfers. The Fall Care Plan dated 2/5/26 identified the resident as at risk for falls and included interventions such as not transferring the resident to a recliner chair. After a facility-reported incident on 2/27/26, the resident was hospitalized for a left femoral neck fracture after attempting to ambulate in her room and falling. The care plan was updated on 3/9/26 to include a ghost alarm to the wheelchair and mattress, but there was no intervention that included use of a floor mat. During observation on 4/14/26, the resident was seated in her wheelchair near the nurse's station, fidgeting and leaning over until her buttocks came over the edge of the seat; a CNA caught her as she slipped out of the wheelchair. No alarm sounded during the observation. Later that day, a floor mat was observed propped against the dresser in the resident's room, and staff interviews indicated the resident should have had a mat on the floor or next to the recliner when sleeping, although the resident was not to be put in the recliner. The DON and Nurse Consultant were informed that the alarm had not activated and that the floor mats had not been care planned.
Improper Handling of Resident Medications During Pass
Penalty
Summary
The facility failed to ensure infection control guidelines were followed during medication administration when an LPN handled a resident’s solid medications with ungloved hands. During observation of medication pass for Resident 59, the LPN prepared the resident’s medications and stated that spironolactone would be held because the resident’s blood pressure was below the ordered parameters. She tore open a plastic pouch containing four tablets, poured them into her ungloved hands, picked up each pill and placed it in a medicine cup, then picked up the spironolactone and disposed of it before giving the resident the remaining pills. During the immediate interview, the LPN was informed that she had handled the pills with ungloved hands. Later, the Clinical Support Nurse and DON were informed of the observation and stated the nurse should have worn gloves if touching the pills. The facility policy on Specific Medication Administration Procedures stated that solid medications should be poured or pushed into a souffle cup while avoiding touching the tablet or capsule unless wearing gloves.
Failure to Notify Responsible Party of Catheter Dislodgement and Replacement
Penalty
Summary
The facility failed to notify a resident's responsible party when a significant change in condition occurred involving the dislodgement and replacement of a urinary catheter. The resident, who was admitted under hospice services for respite care and had severe cognitive impairment along with multiple diagnoses including degenerative disease of the nervous system, dementia, Alzheimer's disease, hypertension, and chronic kidney disease, stood up unassisted and pulled out her urinary catheter. Facility nursing staff immediately contacted hospice services, and a hospice nurse reinserted the catheter without difficulty. Documentation indicated that the dislodged catheter balloon had not been fully inflated as required. Despite the incident and the facility's policy requiring notification of the resident's legal representative in the event of a significant change in condition, there was no evidence that the responsible party was informed about the catheter incident. The facility Administrator believed hospice services had notified the family, but the Hospice Executive Director confirmed that the family had not been notified. The facility's policy also required documentation of notification or attempts in the resident's electronic health record, which was not present in this case.
Failure to Follow Fall Prevention Care Plan Results in Resident Injury
Penalty
Summary
A certified nursing aide (CNA) failed to follow a resident's comprehensive care plan for fall prevention, resulting in a significant accident. The resident, who had diagnoses including dementia, unsteadiness, muscle weakness, and impaired cognition, required substantial assistance for transfers and was at high risk for falls. The care plan specified interventions such as staff assistance with transfers, use of a fall mat, bed in the low position, and a perimeter mattress to define the bed's edges. Despite these directives, the CNA left the resident seated on the edge of the bed unsupervised while retrieving an item, during which time the resident attempted to transfer independently and fell to the floor. Following the fall, the resident was assessed and found to have pain in the torso and lower extremities. Emergency department evaluation revealed acute, displaced fractures of both femurs, with the left femur showing a comminuted fracture and the right femur an acute displaced oblique fracture. The resident required surgical intervention and hospitalization due to the severity of the injuries. The clinical record and staff interviews confirmed that the resident had severe cognitive deficits and did not remember needing assistance with transfers, further emphasizing the necessity of staff supervision as outlined in the care plan. Documentation indicated that the CNA had moved floor mats to position a wheelchair for transfer but left the resident unattended, directly contravening the care plan's requirement for one-person assistance during transfers. The facility's fall management policy aimed to maintain a hazard-free environment and implement preventative measures, but in this instance, the failure to provide adequate supervision and adhere to the care plan led to the resident's fall and subsequent injuries.
Failure to Follow Fall Protocols After Resident Fall
Penalty
Summary
The facility failed to ensure that three certified nurse aides (CNAs) followed established fall protocols after a resident experienced a fall. The incident involved a resident with a history of right-sided hemiplegia, osteoarthritis, and altered mental status, who required substantial to maximal assistance for transfers and was at high risk for falls. During a transfer from the toilet to a wheelchair, the resident was not able to sit back fully in the wheelchair, resulting in her knees hitting the wall and her being lowered to the floor by a CNA. The CNA, along with two other CNAs, subsequently assisted the resident from the floor to her bed without waiting for a nurse to assess the resident, despite the resident expressing pain and distress. Documentation revealed that the CNAs did not follow the Indiana State Department of Health Nurse Aide Curriculum, which instructs staff to call for help immediately and keep the resident in the same position until a nurse examines the resident after a fall. Instead, the CNAs moved the resident before a nurse could assess her condition. There were no written statements from two of the CNAs involved, and the facility lacked a specific policy guiding nurse aides on the required actions following a resident fall, aside from referencing the state curriculum. Subsequent medical evaluation found that the resident had sustained an acute, displaced fracture of the femoral metaphysis and a fracture of the metatarsal of the left foot. The resident was treated at a local emergency department and returned to the facility. Interviews confirmed that the CNAs moved the resident due to her complaints of pain and requests to be moved, but did not adhere to the required protocol of waiting for a nurse assessment before moving a resident after a fall.
Failure to Ensure Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to provide a process for residents to file grievances anonymously, affecting all 54 residents. During a Resident Council meeting, it was revealed that none of the eight residents present knew how to file a grievance anonymously. The facility utilized an application accessible only on facility computers and tablets, requiring residents to inform a staff member to access the app. This process compromised anonymity, as staff members would know who requested to file a grievance. Interviews with the Executive Director, Life Enrichment Director, and Social Services Director confirmed that the grievance app required staff assistance, which could reveal the identity of the resident filing the grievance. The facility's policy allowed for grievances to be filed verbally, in writing, or anonymously, but the current system did not support true anonymity due to the need for staff involvement in accessing the app. This deficiency in the grievance process potentially affected the dignity and rights of all residents in the facility.
Unsanitary Food Handling in Dining Room
Penalty
Summary
The facility failed to serve food in a sanitary manner in one of the three dining rooms observed, potentially affecting all nine residents who ate there. During an observation, a dietary aide was seen carrying two residents' plates with her thumb on the eating surface, which she acknowledged should have been carried from the bottom. Additionally, two other dietary aides were observed touching the eating surface of residents' plates with their thumbs while serving meals. The Director of Food Service confirmed that the food servers should have handled the plates from the bottom to avoid touching the eating surface. The facility's policy, dated 2009, indicated that plates should be handled so that hands do not touch the areas where food or the mouth will be placed.
Failure to Provide Adequate Grooming for a Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for a dependent resident, specifically in relation to facial shaving. Observations on multiple occasions revealed that the resident had multiple white hairs on her chin, approximately half an inch in length, indicating a lack of grooming. The resident, who was severely cognitively impaired and required supervision for personal hygiene, had a care plan that included facial shaving on shower days or as needed. However, despite receiving showers on several documented dates, there was no record of the resident refusing facial shaving, suggesting that the task was not performed as required. Interviews with facility staff, including CNAs and an LPN, confirmed that facial shaving should be provided to residents, including females, unless they preferred to have facial hair. The staff were unaware of any female residents who preferred facial hair, and the LPN acknowledged that the resident should have been shaved. The facility's policy on grooming emphasized the importance of maintaining hair and facial hair, yet the deficiency in care was evident through the observations and lack of documentation regarding the resident's grooming needs.
Failure to Coordinate and Document Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination and documentation of hospice care for a resident who was admitted to hospice. The resident, who had diagnoses including diabetes mellitus with neuropathy and senile degeneration of the brain, was admitted to hospice care as per a physician's order dated 1/9/2025. However, upon review of the hospice communication book on 2/5/2025, it was found that essential sections such as the comprehensive care plan, physician orders, medication list, narcotic count, and visit notes were blank. This lack of documentation was confirmed during an interview with the Director of Nursing (DON), who acknowledged that these documents should have been present in the hospice book. Further investigation revealed that the facility did not have a policy for maintaining a hospice book for communication between the facility and the hospice team. A contract for hospice services, dated 10/4/2021, outlined the responsibilities of both the hospice and the facility, including the provision of documentation such as the hospice plan of care, medication information, physician orders, and clinical notes. The contract also specified that the facility was responsible for maintaining an accurate medical record that included all services and events provided. Despite these contractual obligations, the facility failed to maintain the necessary documentation, leading to a deficiency in the coordination and continuity of care for the resident receiving hospice services.
Failure to Follow Hand Hygiene Protocols During Blood Glucose Testing and Insulin Administration
Penalty
Summary
The facility failed to adhere to standard precautions during routine blood glucose testing and insulin administration for a resident. During a medication administration pass, an LPN gathered supplies and entered the resident's room, donned gloves, and took the resident's blood sugar. After completing the task, the LPN exited the room with gloves on, disposed of the supplies, and removed the gloves. She then donned new gloves to clean the glucometer, removed those gloves, and prepared the insulin without performing hand hygiene at any point. The LPN then entered the resident's room again, donned gloves, and administered the insulin without using alcohol-based hand rub or washing her hands. During an interview, the LPN acknowledged that she should have used alcohol-based hand rub before and after taking the blood sugar and prior to administering the insulin. The facility's policies on medication administration and hand hygiene were reviewed, indicating that hand hygiene should be performed before and after direct physical contact with residents and after removing gloves.
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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 South Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holy Cross Village At Notre Dame Inc | 1.3 mi | ★★★★★ | 20 | 0 |
| Healthwin Health & Rehabilitation | 1.6 mi | ★★★★★ | 34 | 0 |
| Milton Home, The | 2 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of South Bend | 2.1 mi | ★★★★★ | 56 | 0 |
| Cardinal Nursing And Rehabilitation Center | 2.3 mi | ★★★★★ | 0 | 0 |
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