Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 West Bend Nursing And Rehabilitation during CMS and state inspections, most recent first.
Kitchen Not Maintained in Sanitary Condition: The facility failed to keep the kitchen sanitary when surveyors observed a dirty wall around the handwashing sink, 3 greasy skillets with black and brown buildup on both sides, and 2 water heaters covered with dust and debris. The CM acknowledged the areas should have been cleaned and the pans likely needed replacement. The issue had the potential to affect 66 of 67 residents who ate food prepared in the kitchen.
Unsanitary Conditions on 200 Unit: Surveyors observed heavy dust buildup on ceiling vents, blinds, and window sills; a dried brown substance on a wall; brown stains inside a toilet bowl; and used towels and washcloths on bathroom floors in multiple rooms. The HS stated toilets should be cleaned daily and vents, blinds, and window sills should be cleaned on a routine schedule, and the ED provided cleaning policies that called for daily restroom cleaning and weekly dusting of high surfaces and window treatments.
A resident with multiple diagnoses, including dementia and anxiety, was prescribed Ativan to be given before dialysis sessions. Facility staff did not notify the resident's responsible party about the new medication or discuss its risks and benefits prior to administration, despite facility policy requiring such notification. Documentation only indicated that medications were reviewed, without specifying that Ativan was discussed.
A resident was administered Ativan prior to dialysis treatments without adequate assessment or documentation of behavioral need, following only a single reported incident of restlessness. Facility staff did not complete required behavioral assessments or monitor the resident's response to the medication, and the responsible party was not informed of its use. The resident was observed to be alert and without negative behaviors during this period, indicating the medication was used as a chemical restraint without sufficient justification.
A resident with dementia and anxiety was prescribed Ativan for use before dialysis, but staff failed to create a care plan addressing this psychotropic medication until more than two months after it was started, contrary to facility policy and best practices.
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and pantries, affecting all residents who consumed food from these areas. Observations revealed significant cleanliness issues, including buildup of substances on kitchen equipment, unsanitary conditions in dining areas, and inadequate food storage practices. Staff interviews highlighted a lack of clarity on cleaning responsibilities and food disposal, despite the existence of a cleaning schedule and adherence to the FDA Food Code.
A resident's surgical wound condition worsened, showing signs of infection, but the facility failed to notify the surgeon. Despite the resident's requests for dressing changes, the wound was not properly managed, and the facility's wound team made treatment changes without the surgeon's input. Interviews revealed a lack of communication and follow-up, with the surgeon's office confirming they were not informed of the condition change.
The facility failed to provide the required Notice of Transfer/Discharge forms for two residents transferred to an acute care facility. One resident, with chronic conditions, was sent to the ER unresponsive, and although her husband was notified, the necessary documentation was missing. Another resident, transferred due to back pain and vomiting, also lacked documented transfer paperwork for two hospitalizations. The absence of documentation was confirmed by the Administrator.
The facility failed to provide the Bed Hold Policy to two residents during hospital transfers. One resident, with chronic conditions, was sent to the ER unresponsive, and her husband was notified, but no documentation of the policy was provided. Another resident, hospitalized twice, did not recall receiving the policy, and the record lacked documentation of its provision. The ED confirmed the absence of necessary transfer paperwork.
The facility failed to conduct timely Care Plan meetings with two residents, leading to a deficiency in care planning. One resident did not have Care Plan meetings following several MDS assessments, except for one conducted after an annual MDS assessment. Another resident did not have quarterly Care Plan meetings as required, despite having an intact cognition and multiple diagnoses. The facility's policy mandates timely meetings, which were not adhered to in these cases.
A facility failed to perform and document daily dressing changes for a resident with a surgical wound, as ordered by a physician. The resident reported that the dressing had not been changed for two days, and upon inspection, it was found to be dated four days prior with signs of infection. An LPN admitted to not changing the dressing and incorrectly signing off on the Treatment Administration Record. The facility could not provide a relevant policy when requested.
A resident with a surgical wound did not receive daily dressing changes as ordered by the physician. The dressing was not changed for two days, despite the resident's requests, and was found to be loose with drainage. An LPN failed to communicate the need for dressing changes to the evening shift, and the Treatment Administration Record was inaccurately signed. The DON noted the absence of a specific policy on following physician orders.
A resident was prescribed cephalexin for a UTI, but a lab report showed no bacterial growth, indicating the antibiotic was unnecessary. The facility failed to notify the NP to discontinue the medication until five days after receiving the lab results, leading to a deficiency.
A resident with a history of hemiplegia, diabetes, and anxiety did not receive fresh ice water as per his preference, impacting his hydration needs. Despite the facility's policy to provide fresh water to all residents, the resident had to request water from the nurse's station, and his care plan did not address his preference for fresh ice water. Observations confirmed the absence of water in his room, and a CNA stated she only provided water upon request.
A facility failed to maintain infection control standards during a dressing change for a resident with multiple health conditions. An LPN did not perform hand hygiene after removing a soiled dressing and placed clean supplies on the bed without a barrier, contrary to facility policy. The LPN later acknowledged these lapses in procedure.
Kitchen Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to prepare food under sanitary conditions in 1 of 1 kitchens. During a kitchen tour with the Culinary Manager, the wall around the handwashing sink was observed to be dirty with brown and yellow spots and drips, 3 stainless steel skillets were black and brown with greasy buildup on both the inside and outside surfaces, and the tops of 2 water heaters were covered with dust and debris. During interview, the Culinary Manager stated the wall near the handwashing sink should have been cleaned, the frying pans probably should be replaced, and the tops of the water heaters should have been free of dust and debris. The report states this had the potential to affect 66 of 67 residents who ate food prepared in the kitchen.
Unsanitary Conditions on 200 Unit
Penalty
Summary
The facility failed to maintain a sanitary environment on the 200 Unit, which was the only unit identified in the report as having this issue. During a continuous observation of the unit’s environment and a later tour with the Housekeeping Supervisor, surveyors observed two ceiling air vents above the 200 Unit medication cart with a heavy buildup of dust, heavy dust buildup on the blinds and window sills in rooms 208, 216, and 218, a dried brown substance on the wall in the corner of a room, and brown stains inside the toilet bowl in a room identified in the report. Used towels and washcloths were also observed on the bathroom floors in rooms 208, 216, 212, and 220. During interview, the Housekeeping Supervisor stated toilets should be cleaned daily, including for residents who are always incontinent, and said the buildup in the toilet was from hard water. The Housekeeping Supervisor also stated blinds and window sills should be cleaned and hallway air vents should be dusted weekly. The Executive Director provided the facility’s current Daily Cleaning Procedure and Restroom Cleaning Procedure, which included daily cleaning and disinfecting of resident restrooms, weekly high dusting, and cleaning/dusting of window blinds and window sills, as well as cleaning the toilet bowl and exterior of the toilet.
Failure to Notify Responsible Party of New Medication Prior to Administration
Penalty
Summary
The facility failed to ensure timely notification of a resident's responsible party regarding the initiation of a new medication, Ativan, and the associated risks and benefits prior to its administration. Interviews with the Social Service Director at a local dialysis center revealed that the resident, who had diagnoses including Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety, was prescribed Ativan to be administered before dialysis sessions. The dialysis center staff observed the resident arriving lethargic and requested discontinuation of the medication after several weeks. Documentation showed that the responsible party was not informed about the new medication at the time of its initial administration, and the addition of Ativan was not discussed during a care plan meeting, despite a note indicating that medications were reviewed. Further interviews with the Memory Care Director, Assistant Director of Nursing, and Director of Nursing confirmed that the responsible party was not notified about the prescription of Ativan prior to its administration. The only documentation of notification was a care plan note stating that medications were reviewed, but it did not specify that Ativan had been discussed. The facility's policy required that all changes in a resident's condition, including new medications, be communicated to the responsible party prior to the end of the assigned shift, with documentation of the notification and response. This policy was not followed in this instance, resulting in a deficiency.
Failure to Prevent Unnecessary Use of Psychotropic Medication as Chemical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraint when Ativan, a psychotropic medication, was administered prior to off-site dialysis treatments without adequate assessment or documentation of need. The medication was prescribed following a single report of the resident being 'figgity' and pulling at his dialysis port, but there were no further documented incidents of negative behaviors or agitation. Despite this, Ativan was ordered and administered three times weekly before dialysis appointments for several months. Interviews with facility staff, including the Memory Care Director and Assistant Director of Nursing, revealed that no behavioral assessments were completed prior to the initiation of Ativan, nor were there follow-up assessments to monitor the resident's response or potential side effects. The Psychiatric Nurse Practitioner prescribed the medication based on a request from the Director of Nursing, who had been informed by the dialysis center of the resident's agitation. However, the only documented behavioral incident was from several weeks prior, and subsequent observations showed the resident to be alert, well-groomed, and without negative behaviors. The dialysis center later reported that the resident was arriving lethargic and that the responsible party was unaware of the Ativan use. The facility's own policy required assessment and documentation of symptoms and therapeutic goals prior to initiating psychotropic medications, but this was not followed. The lack of assessment, documentation, and monitoring led to the administration of a psychotropic medication without clear evidence of medical necessity, resulting in the resident being chemically restrained.
Failure to Timely Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan in a timely manner for a resident who was prescribed an anti-anxiety medication, Ativan, to be administered prior to dialysis sessions. The resident had multiple diagnoses, including Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety. The order for Ativan was given by the Psychiatric Nurse Practitioner following a request from the Memory Care Director, and the medication was administered regularly as prescribed. However, review of the resident's clinical record and care plans revealed that a care plan addressing the use of Ativan for anxiety was not initiated until over two months after the medication was started. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that a care plan should have been created immediately after the Ativan was ordered, but this was not done. The facility's policy on psychotropic management requires that symptoms and therapeutic goals be documented prior to initiating such medications, and that care plans be developed to promote the resident's highest practicable well-being. The lack of a timely care plan for the use of Ativan constituted a failure to meet these requirements.
Sanitation Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and pantries, affecting all 57 residents who consumed food from these areas. During a series of observations, surveyors noted significant cleanliness issues, including a thick buildup of black substance on the burner grates and grease accumulation on the gas range and surrounding areas. Additionally, a ceiling vent above a prep table was covered in a black substance resembling mold, and the handwashing sink was dirty with a red dried substance. The Culinary and Nutrition Manager acknowledged the need for cleaning, despite the existence of a cleaning checklist. In the dining areas, further unsanitary conditions were observed. The 2nd Floor Dining Room had a range and oven with food debris and grease buildup, which staff acknowledged should be cleaned by the kitchen. The Main Dining Room had a leaking ice machine with lime buildup and dirty walls, and several chairs had food debris on them. The Housekeeping Supervisor and Maintenance Director confirmed the issues, with responsibilities for cleaning divided between kitchen and housekeeping staff. In the pantries and kitchenettes, food storage practices were inadequate. Expired and undated food items were found, including hot chocolate, condiments, yogurt, and pizza sauce, some of which were leaking. Staff interviews revealed a lack of clarity on responsibilities for discarding expired items and cleaning. The Executive Director and Corporate Nurse indicated the facility followed the FDA Food Code but lacked a specific policy for kitchen maintenance. A cleaning schedule was provided, but it was not effectively implemented, leading to the observed deficiencies.
Failure to Notify Surgeon of Wound Condition Change
Penalty
Summary
The facility failed to notify a resident's surgeon of a change in the condition of a surgical wound, which was a requirement for one of the residents reviewed for skin conditions. The resident, who had undergone a left above-the-knee amputation revision and treatment for a wound infection, reported that her dressing had not been changed for two days, despite her requests to the evening shift staff. Upon observation, the dressing was found to be loose, with a large amount of reddish-brown drainage, and the wound showed signs of infection, including redness and an open area. The resident's medical history included chronic hematogenous osteomyelitis, chronic obstructive pulmonary disease, chronic diastolic heart failure, and peripheral vascular disease, among other conditions. The facility's records indicated that the wound had initially been well-approximated with no signs of infection. However, subsequent assessments showed a worsening condition, with the wound dehiscing and showing signs of infection. Despite these changes, the surgeon was not notified, and the facility's wound team and nurse practitioner made treatment changes without the surgeon's input. Interviews with facility staff revealed a lack of communication and follow-up regarding the notification of the surgeon. The LPN responsible for notifying the surgeon did not confirm whether the surgeon had received the notification or provided any treatment recommendations. The surgeon's office confirmed that they had not been contacted about the change in the wound's condition, and the facility's documentation did not include any record of communication with the surgeon regarding the changes in the resident's wound condition.
Failure to Provide Transfer/Discharge Documentation
Penalty
Summary
The facility failed to provide the required Notice of Transfer/Discharge form when residents were transferred to an acute care facility. For Resident 4, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and heart failure, the record review showed that after being found unresponsive, the resident was sent to the emergency room. Although the resident's husband was notified by phone, there was no documentation that the Notification of Transfer/Discharge form was provided to either the resident or her husband. An interview with the Executive Director confirmed the absence of transfer paperwork in the resident's records. Similarly, for Resident 16, who was transferred to the hospital due to lower back pain and vomiting, the facility did not document the completion of a transfer/discharge assessment or provide the necessary forms. Despite the family and primary care physician being notified of the transfer, the records lacked documentation of the transfer paperwork for two separate hospitalizations. The Administrator confirmed the absence of the required documentation, and no policy regarding the documentation of a transfer/discharge assessment was provided during the survey.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to residents when they were admitted to the hospital, as required. This deficiency was identified for two residents who were reviewed for hospitalization. Resident 4, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and heart failure, was found unresponsive and sent to the emergency room. Although her husband was notified by phone of the transfer, there was no documentation that the Bed Hold Policy was provided to either the resident or her husband. Additionally, the facility's Executive Director (ED) confirmed the absence of transfer paperwork, including the Transfer/Discharge form for Resident 4. Similarly, Resident 16, who had been hospitalized twice in the last four months, did not recall receiving a bed hold policy. The nursing progress notes indicated that Resident 16 was sent to the emergency department due to lower back pain and vomiting, and later admitted to the hospital. Despite the notifications to the Director of Nursing, the resident's family, and the Primary Care Physician, the record lacked documentation that the Bed Hold Policy was provided during the transfers. The ED acknowledged the absence of transfer paperwork, including the notice of transfer and bed hold policy paperwork, and provided the current Bed Hold Policy, which mandates that residents be given the policy at the time of hospital transfer or therapeutic leave.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct timely Care Plan meetings with residents and/or their representatives for two residents, leading to a deficiency in care planning. Resident 47 did not have Care Plan meetings following several Minimum Data Set (MDS) assessments, except for one conducted after the annual MDS assessment in February 2024. Despite regular meetings with the Social Services Director, formal Care Plan meetings were not held as required. The Executive Director confirmed the lack of regular Care Plan meetings for Resident 47 after MDS assessments. Similarly, Resident 38 did not have Care Plan meetings on a quarterly basis as required. Despite having an intact cognition and a diagnosis of hypertension, general anxiety disorder, and depression, there was no documentation of Care Plan meetings from June 2024 through December 2024. The Social Service Director acknowledged the absence of formal Care Plan meetings after the quarterly assessments in August and November 2024. The facility's policy, dated August 2023, mandates that the Interdisciplinary Team (IDT) meet with residents and/or their representatives at a mutually agreed time and location, which was not adhered to in these cases.
Failure to Perform and Document Dressing Changes
Penalty
Summary
The facility failed to meet professional standards of quality care by not ensuring that a resident's dressing changes were completed as ordered. During an observation and interview, the resident reported that her dressing, which was supposed to be changed daily, had not been changed for two days. The dressing was dated four days prior, and upon inspection, it was found to have a large amount of reddish-brown thick drainage, an opening in the center of the wound, and erythema around the surgical site. The resident had requested the dressing change to be completed later in the day due to outings, but it was not done. A review of the resident's records showed a physician's order for daily dressing changes, which were documented as completed on the Treatment Administration Record for the days in question. However, during an interview, the LPN admitted to not changing the dressing and acknowledged that the dressing changes should not have been signed off as completed. The facility was unable to provide a policy regarding the dressing change procedure when requested.
Failure to Follow Physician's Order for Dressing Change
Penalty
Summary
The facility failed to ensure that a resident received treatment per the physician's order, specifically regarding the changing of a dressing on a surgical wound. The resident, who had a left above-the-knee amputation, was supposed to have her dressing changed daily. However, during an observation and interview, the resident indicated that the dressing had not been changed for the past two days, despite her requests to the evening shift staff. The dressing was dated four days prior, and upon inspection, it was found to be loose with a large amount of reddish-brown thick drainage, and the wound area was red and open. The resident's medical history included chronic hematogenous osteomyelitis, infection following a procedure, and other chronic conditions. The physician's order specified a detailed dressing change procedure, which was not followed. An LPN acknowledged that the dressing change was not communicated to the evening shift, and the Treatment Administration Record was inaccurately signed as completed. The Director of Nursing indicated that there was no specific policy on following physician orders, only a standard practice.
Failure to Discontinue Unnecessary Antibiotic
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary antibiotic medication, leading to a deficiency. Resident 41, who had diagnoses including acute osteomyelitis of the left ankle and foot and a stage 2 pressure ulcer on the left heel, was prescribed cephalexin for a urinary tract infection. The antibiotic was ordered on 11/28/2024 and was supposed to be discontinued on 12/4/2024. However, a lab report dated 11/30/2024 indicated no bacterial growth in the urine specimen, suggesting that the antibiotic was no longer necessary. Despite this, the facility did not notify the Nurse Practitioner to discontinue the antibiotic treatment until 12/5/2024, five days after the lab results were received. The Infection Preventionist confirmed that it was standard practice to stop antibiotics based on such lab results.
Failure to Provide Fresh Ice Water to Resident
Penalty
Summary
The facility failed to ensure that a resident received fresh ice water according to his preference, which was necessary to maintain proper hydration. Resident 21, who had a history of hemiplegia, hemiparesis, type 2 diabetes mellitus with hyperglycemia, and anxiety disorder, expressed during interviews that he did not receive fresh ice water daily as he desired. He reported that the last time water was delivered to his room was on two specific dates in November, and he had to go to the nurse's station to request water. Observations confirmed the absence of a water cup in his room. The resident's care plan, which required assistance or monitoring of nutrition, hydration, and elimination, did not address his preference for fresh ice water. A CNA indicated that she only provided water to residents who requested it and did not leave water in rooms unless asked. The facility's Hydration Management policy, which was revised in 2017, stated that fresh water or other preferred beverages should be passed to all residents on each shift unless medically contraindicated. However, this policy was not followed for Resident 21, leading to the deficiency.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain acceptable infection control standards during a surgical dressing change for a resident. During the observation, an LPN removed a soiled dressing from the resident's wound, then removed her gloves and donned a new pair from her uniform pocket without performing hand hygiene. Additionally, the LPN placed the clean dressing supplies directly on the resident's bed without using a barrier, which is against the facility's policy. The resident involved had multiple diagnoses, including chronic hematogenous osteomyelitis, infection following a procedure, chronic obstructive pulmonary disease, chronic diastolic heart failure, and peripheral vascular disease, among others. During an interview, the LPN acknowledged that she should have washed her hands after removing the soiled dressing and should have used a barrier for the dressing supplies. The facility's policy on dressing change clean technique, provided by the DON, specifies the need for a clean field and hand hygiene, which were not followed in this instance.
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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) |
|---|---|---|---|---|
| Briarcliff Health & Rehabilitation Center | 2.2 mi | ★★★★★ | 17 | 0 |
| Milton Home, The | 3.3 mi | ★★★★★ | 6 | 0 |
| Cardinal Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 0 | 0 |
| Holy Cross Village At Notre Dame Inc | 4 mi | ★★★★★ | 20 | 0 |
| Wellbrooke Of South Bend | 4.1 mi | ★★★★★ | 19 | 0 |
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