Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Wabash during CMS and state inspections, most recent first.
Surveyors found that kitchen food storage and preparation areas were not maintained in a safe and sanitary condition. Observations revealed extensive food splatters and grease buildup on floors and around the stove, steamer, and griddle, as well as thick burnt-on residue inside and on the face of an oven. A prep table had scattered food debris on shelving, and an open container holding pot lids contained dried egg, sausage, and shredded cheese mixed with the lids. On re-observation, similar unsanitary conditions persisted, with multiple dried food substances and splatters on the floors in several locations and continued heavy grease buildup on the oven. These findings occurred despite written cleaning schedules, aide cleaning lists, and a preventative maintenance policy requiring kitchen equipment to be kept free of buildup.
Surveyors found that medication labeling and storage practices were not followed on two medication carts. On one cart, loose unidentified tablets were discovered in a drawer, contrary to the expectation that such medications be destroyed. On another cart, multiple insulin glargine pens and a bottle of olopatadine eye drops for two residents were missing required labeling elements, including proper resident labels and opened dates, and one insulin pen had an opened date that an RN believed was either expired or written incorrectly. The DON confirmed that facility policy requires medications to be labeled with the resident’s name, ordering provider, date opened, expiration date, and to be stored in an orderly manner with each resident’s medications kept separate and multi-dose containers dated when opened.
A resident with a documented history of C. diff, ongoing loose stools, and bowel incontinence had physician orders and care plans requiring contact precautions and enhanced barrier precautions, including use of gowns and gloves and hand hygiene with soap and water. Surveyors observed inconsistent and incorrect isolation signage at the room, with contact precaution signs removed when COVID-19 precautions ended and only EBP signage left in place despite ongoing C. diff precautions. A PT and a CNA entered the room without PPE, handled the wheelchair and gait belt with bare hands, transported the resident to therapy and the dining room, and then touched other items and equipment without performing hand hygiene, while the resident also did not perform hand hygiene. Interviews with the IP, DON, and other staff showed confusion between EBP and contact precautions, incomplete education of non-nursing departments, and a failure to follow the facility’s own infection control and contact precaution policies.
The facility did not accurately post required daily nurse staffing information because the daily staffing reports, although listing the number of nursing staff scheduled or working each shift, did not include the facility census. Surveyors observed multiple posted reports without census data and, upon review of historical reports, found that only a small number contained census information while the majority did not. During interview, the DON reported she was unaware that the automated staffing reports omitted census information, despite acknowledging that census affects staffing requirements.
A resident with multiple medical conditions was left undressed and uncovered during pericare by two CNAs, failing to maintain her dignity and privacy. The CNAs acknowledged the oversight, and the facility's policy did not address maintaining dignity during the procedure, contrary to state guidelines.
A resident with diabetes experienced a change in condition and was hospitalized for hypoglycemia. Despite having a care plan to monitor for adverse effects of hypoglycemic medications, the facility failed to perform a blood sugar test during the incident. The resident exhibited symptoms such as incoherence and involuntary twitching, and was later found to have a blood sugar level of 29 mg/dL at the hospital. Interviews revealed a lack of awareness and action by staff regarding the resident's unstable diabetes.
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. A resident with emphysema was observed lying flat despite orders to elevate the bed, and staff were unaware of this requirement. Another resident wore support hose without a current order, and staff continued applying them daily. A third resident did not receive ordered hemoccult testing, and there was no documentation of the results. These issues indicate a lack of communication and adherence to physician's orders.
A facility failed to provide adequate hydration to a resident with recurrent UTIs. Observations showed the resident's water jug was consistently full, warm, and without ice, indicating insufficient fluid intake. Despite care plans and a physician's order to encourage fluids, the resident was unable to access the water independently due to functional impairments. Interviews with LPNs confirmed the resident could drink if assisted, but the facility's hydration management policy was not effectively implemented.
A resident with dementia was prescribed olanzapine, an antipsychotic, without proper indication. Despite having a history of delusional thoughts, assessments showed no significant behavioral disturbances. The facility's documentation did not support the necessity of the medication, as the resident's symptoms were not distressing, and non-pharmacological interventions were in place. The use of olanzapine was not adequately justified, highlighting a deficiency in medication management.
The facility failed to follow infection control procedures during blood glucose testing for two residents and perineal care for another. An LPN did not use a barrier or disinfect supplies during glucose testing, while a CNA improperly wiped a resident's perineal area, contrary to infection prevention guidelines.
Unsanitary Kitchen Equipment and Food Storage/Preparation Areas
Penalty
Summary
The deficiency involves the facility’s failure to store and prepare food under safe and sanitary conditions in the kitchen, affecting all 92 residents who received food from this area. During an initial kitchen observation, surveyors noted numerous food splatters of various colors on the floor near the doorway, brown and black grease buildup on the side of the steamer, and black and brown splatter marks along the floor between the stove and steam warmer, including a bun top lying face up on the floor between these appliances. The bottom of the left oven had thick, burnt-on black buildup approximately the thickness of a pencil eraser, and the oven face had a thick black grease streak running down the front. Additional grease streaks were observed on the right side of the griddle. The prep table in front of the stove had multiple food particles, including shredded cheese and breadcrumbs, scattered throughout the storage shelves. An open container used to store pot lids contained dried egg, sausage pieces, and shredded cheese mixed in with the lids. The Dietary Manager reported that the stove was cleaned weekly, ovens monthly, and floors were supposed to be swept nightly. A follow-up kitchen observation showed that unsanitary conditions persisted. Numerous food substances, including honey-colored, black, dark brown, red, and light pink dried liquids and splatters, were present on the floor in multiple areas, including near the door frame, behind the prep table, next to the bread cart, and in front of the flour container. A dried yellow food substance about the size of a tennis ball was observed on the floor near the trash can by the hand-washing station. The oven face still had the thick black grease streak, and the bottom of the left oven continued to have the same burnt-on black buildup. Dark brown and black food splatters and grease marks remained on the floor between the stove, steamer, and wall. Review of the facility’s weekly cleaning schedule and AM/PM aide cleaning lists showed that equipment and surfaces were scheduled for regular cleaning, and a facility policy on kitchen equipment preventative maintenance required burner tops and fryers to be kept free of buildup. However, despite documented schedules and logs, the observed conditions demonstrated that kitchen equipment and floors were not maintained in a clean and sanitary manner.
Improper Medication Labeling and Storage in Medication Carts
Penalty
Summary
Surveyors identified a failure to ensure medications were properly labeled and securely and orderly stored. During observation of the 200-hallway medication cart, accompanied by QMA 3, a white round pill imprinted TCL 340 and a yellow oblong pill imprinted C55 were found loose in the second drawer from the top of the cart. QMA 3 stated that any loose medications found in the medication cart should be destroyed in the drug buster and that medication carts were cleaned out on an as-needed basis. This cart stored medications for 39 of 51 residents. On the 100-hallway medication cart, accompanied by RN 4, surveyors observed multiple insulin pens and an eye drop bottle that were not labeled in accordance with facility policy and accepted standards. One prefilled disposable insulin glargine pen with approximately 20 units remaining had only a handwritten resident name and an opened date that RN 4 indicated was either expired or possibly written incorrectly, and the pen lacked a proper resident label. A second insulin glargine pen with approximately 25–30 units remaining had a handwritten resident name but no opened date and no label. A bottle of olopatadine 0.2% eye drops labeled for a resident lacked an opened date, and another insulin glargine pen with approximately 150 units remaining had only a handwritten resident name and opened date on the lid, without a resident label on the pen itself. The DON stated that all medications should be labeled with the resident's name, ordering provider, date opened, and expiration date, and the facility’s policy required orderly storage, individual resident compartments, and dating of multi-dose containers when opened.
Failure to Implement Contact Precautions and Hand Hygiene for Resident With C. diff
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement appropriate infection prevention and control measures, specifically contact precautions and hand hygiene, for a resident with an ongoing Clostridioides difficile (C. diff) infection. The resident had a history of C. diff, was admitted with C. diff and a UTI, and continued to experience loose, unformed stools and bowel incontinence over an extended period. Clinical records documented multiple positive C. diff stool tests, repeated courses of oral vancomycin, and ongoing abdominal discomfort and loose stools. Orders and care plans indicated the resident required contact precautions for C. diff and enhanced barrier precautions (EBP) during high-contact care, with specific instructions for staff to wear gowns and gloves and to perform hand hygiene with soap and water before and after care. Surveyors observed inconsistent and incorrect use of isolation signage and precautions at the resident’s room. Initially, an EBP sign was posted under the resident’s nameplate, but later this was removed and replaced with a contact precautions sign. The Infection Preventionist and DON acknowledged confusion over which sign should have been in place, and the Infection Preventionist stated the resident probably should have remained on contact precautions the whole time due to C. diff. Documentation showed that when COVID-19 droplet precautions were discontinued, staff removed the contact precaution sign and left only the EBP sign, despite existing orders for C. diff contact precautions. Progress notes also conflicted, with some entries indicating no isolation precautions were needed while others documented that C. diff precautions and contact isolation were in place. Direct care observations showed staff and therapy personnel did not follow required contact precautions or hand hygiene practices when interacting with the resident or her environment. A physical therapist entered the resident’s room without PPE, handled the resident’s gait belt and wheelchair with bare hands, transported the resident to and from therapy, and did not perform hand hygiene upon entering or exiting the room; the resident also did not perform hand hygiene. The therapist later stated he believed the contact precaution sign applied mainly to nursing staff and that hand hygiene was addressed by occupational therapy. A CNA similarly entered the resident’s room without PPE, handled the wheelchair with bare hands, transported the resident to the dining room, and then obtained and served coffee without washing hands, later acknowledging she should have washed her hands because the resident had a bacterial infection. Interviews with nursing staff confirmed that the resident required assistance with toileting and handwashing with soap and water due to C. diff, and that gowns and gloves were to be worn when providing personal care or touching personal items, but these practices were not consistently followed. Additional interviews with the Infection Preventionist, DON, and a clinical support specialist revealed that contact precautions were intended for residents with transmissible infections such as C. diff and MRSA, while EBP was for residents with devices or wounds and was described as protecting the resident from staff. The Infection Preventionist stated that staff education on isolation was primarily directed to nursing staff, as other departments were not considered to provide hands-on care, even though therapy and housekeeping staff entered the resident’s room and interacted with the environment. The facility’s own policies on the Infection Prevention and Control Program and Guidelines for Contact Precautions required surveillance, monitoring of compliance, appropriate signage, and use of gloves and handwashing after contact with the resident or potentially contaminated environmental objects. Despite these policies and the resident’s documented diagnosis and orders, the facility did not ensure consistent implementation of contact precautions, correct signage, and required hand hygiene for all staff interacting with the resident and her environment.
Failure to Include Facility Census on Daily Posted Nurse Staffing Reports
Penalty
Summary
The facility failed to ensure required daily nurse staffing information was accurately posted because the daily staffing reports did not include the facility census, affecting all 51 residents. Surveyors observed on multiple dates that the daily staffing reports posted in the 100 hallway near the Social Services office listed the number of nursing staff scheduled and/or working for each shift but did not include the corresponding facility census. Additional review of Daily Staffing Reports from early December through mid-January showed that only four reports contained census information, while the remaining 42 lacked this required data. During an interview, the DON stated she was unaware that the automated Daily Staff Reports were missing census information and acknowledged that census was important because it would affect staffing requirements from one day to the next. No specific resident medical histories or conditions were described in the report, only that 51 of 51 residents had the potential to be affected by the incomplete public posting of staffing information.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
The facility failed to maintain a resident's dignity and provide privacy during personal care for a resident with multiple medical conditions, including morbid obesity, multiple sclerosis, and chronic pain syndrome. The resident, who was cognitively intact and required total assistance for personal hygiene, was observed during a personal care session where two CNAs were performing pericare. During this process, the resident was left fully undressed without any clothing or covering, with her sheet and blanket placed on a chair next to her bed. The CNAs left the resident lying flat on top of her brief, instructing her to finish moving her bowels, and only helped her put on a shirt without providing any other coverings. The CNAs involved acknowledged the oversight, with one admitting to forgetting to cover the resident with a sheet, which was not her usual practice. The facility's policy on perineal care for incontinence did not address maintaining dignity during the procedure. The Indiana State Department of Health Nurse Aide Curriculum emphasizes the importance of providing resident privacy and maintaining dignity by not exposing the body unnecessarily during such procedures. This incident highlights a failure to adhere to these guidelines, resulting in a deficiency in maintaining the resident's dignity and privacy.
Failure to Assess Resident's Change in Condition Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident with a change in condition was properly assessed prior to hospitalization. Resident 51, who had been admitted with diagnoses including a displaced intertrochanteric fracture, type 2 diabetes mellitus with diabetic chronic kidney disease, and anxiety disorder, experienced a significant change in condition. The resident became incoherent and was later hospitalized for hypoglycemia. Despite having a care plan in place to monitor for adverse effects of hypoglycemic medications, the facility did not perform a blood sugar test during the change in condition. On the evening of the incident, the resident was found to be unable to communicate her needs and exhibited symptoms such as staring into space, pinpoint slow reactive pupils, and involuntary twitching. The resident was sent to the hospital where a blood sugar level of 29 mg/dL was recorded, indicating severe hypoglycemia. The facility's clinical records lacked documentation of any blood sugar tests conducted during this period, which was a critical oversight given the resident's diabetic condition and the symptoms presented. Interviews with facility staff revealed that there was a lack of awareness and action regarding the resident's unstable diabetes. LPN 4, who attended to the resident, did not consider checking the resident's blood sugar despite the evident symptoms. The Director of Nursing indicated that a blood sugar test should have been conducted with the change in condition. The facility's policy on hyper/hypoglycemia management was not followed, as it required blood glucose monitoring when signs of hypoglycemia were present.
Failure to Follow Physician's Orders for Residents
Penalty
Summary
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. For Resident 29, the clinical record indicated a physician's order to elevate the head of the bed to alleviate shortness of breath due to emphysema and low oxygen saturation. However, multiple observations showed the resident lying flat, and staff members, including CNAs and an LPN, were unaware of the order to elevate the bed. The facility's documentation did not clearly communicate this requirement to the staff, resulting in non-compliance with the physician's order. Resident 37 was observed wearing support hose despite the absence of a current physician's order for them. The resident's previous order for support hose had been discontinued, yet staff continued to apply them daily. Interviews with staff revealed a lack of awareness regarding the absence of a current order, and a new order was only obtained after the deficiency was noted. This oversight indicates a failure to update and communicate changes in treatment orders effectively. For Resident 44, the facility did not complete or document the required hemoccult testing as ordered by the physician. Despite the resident's symptoms of abdominal distention and black, tarry stools, the necessary tests were not performed, and there was no documentation of the results. Interviews with the Nurse Consultant and DON confirmed the lack of documentation and failure to follow through with the physician's orders. This deficiency highlights a gap in the facility's process for managing and executing diagnostic orders.
Failure to Ensure Adequate Hydration for Resident with Recurrent UTIs
Penalty
Summary
The facility failed to ensure that a resident with recurrent urinary tract infections received sufficient fluids. Observations revealed that the resident's water jug was consistently full, warm, and without ice, indicating that the resident was not consuming the water provided. The resident's clinical record showed a history of urinary tract infections and a physician's order to push fluids regardless of urinalysis results. Care plans indicated the need to encourage fluid intake, but the resident was unable to independently access the water jug due to functional impairments. Interviews with LPNs confirmed that the resident could drink from a straw if the water was handed to her, but she was unable to reach the water jug from her bed. The facility's hydration management policy aimed to identify residents at risk for dehydration and implement individualized interventions, but these measures were not effectively executed for this resident. The repeated observations of the untouched water jug suggest a lack of adherence to the care plan interventions designed to promote adequate hydration for the resident.
Inappropriate Use of Antipsychotic Medication for a Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with dementia did not receive antipsychotic medications without proper indication. Resident 5, who was diagnosed with several conditions including Parkinson's disease, psychotic disorder with delusions, and dementia, was observed to be taking olanzapine, an antipsychotic medication. Despite having a history of delusional thoughts, the resident's Minimum Data Set (MDS) assessments over several months indicated no hallucinations or delusions. Additionally, behavior analysis reports and medication administration records showed no significant behavioral disturbances or delusions that would justify the continued use of olanzapine. The resident's care plans included interventions for altered behaviors and exit-seeking behaviors, such as offering diversionary activities and monitoring for wandering triggers. However, the psychiatric Nurse Practitioner noted that the resident had intermittent delusional thoughts that were not distressing and reported that olanzapine was effective. Despite this, the facility's documentation did not support the necessity of the antipsychotic medication, as the resident's symptoms were not distressing, and non-pharmacological interventions were in place. The facility's policy on psychotropic medication usage requires that such medications be deemed medically necessary by the prescriber, with appropriate diagnosis or documentation to support their use. The report highlights that the use of olanzapine in this case was not adequately justified, as the resident's symptoms were not distressing, and there was a lack of supporting documentation for the continued use of the medication. Furthermore, olanzapine carries a black box warning for elderly patients with dementia-related psychosis, indicating an increased risk of death, which underscores the importance of careful consideration before prescribing such medications.
Infection Control Deficiencies in Blood Glucose Testing and Perineal Care
Penalty
Summary
The facility failed to adhere to infection prevention and control procedures during blood glucose testing for two residents. An LPN was observed conducting blood glucose tests for two residents without placing a barrier on the bedside table before placing the glucometer supplies. After testing, the LPN did not disinfect the bottle of glucometer strips or the plastic bag before returning them to the medication cart. This practice was contrary to the facility's policy, which required appropriate infection control techniques during testing procedures. Additionally, the facility did not follow proper infection control procedures during perineal care for a resident. A CNA was observed wiping the resident's perineal area from back to front, which is against the recommended practice of wiping from front to back to prevent infection. The resident was incontinent of bowel at the time, and the CNA acknowledged that the technique used was inappropriate. The facility's policies and procedures, as well as the Indiana State Department of Health Nurse Aide Curriculum, emphasize the importance of infection prevention and control techniques. However, the staff's actions during these observations did not align with these guidelines, leading to deficiencies in infection control practices.
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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 Wabash
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Wabash Skilled Nursing Facility West | 0.4 mi | ★★★★★ | 8 | 0 |
| Waters Of Wabash Skilled Nursing Facility East The | 0.4 mi | ★★★★★ | 5 | 0 |
| Autumn Ridge Rehabilitation Centre | 1 mi | ★★★★★ | 4 | 0 |
| Vernon Health & Rehabilitation | 2.8 mi | ★★★★★ | 6 | 0 |
| Rolling Meadows Health Care Center | 11 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.