Wellbrooke of Crawfordsville

In the surveyor’s words

From the most serious findings on record at Wellbrooke of Crawfordsville, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 17, 2023

  A. Based on interview, observation, and record review, the facility failed to ensure that staff used the assistance of two people when providing care and staff had the proper knowledge of the use of a low air loss mattress to prevent a resident's fall out of bed, which resulted in harm when the resident obtained a fractured femur (thigh bone) that required surgery for 1 of 14 residents reviewed for accidents (Resident 27). B. Based on interview, observation, and record review, the facility failed to ensure hot water temperatures were maintained within safe range for 3 of 14 residents reviewed for accidents (Residents 11, 40, and 26). Findings include: A. […]

• No harm, potential for more than minimal, patternF812Aug 7, 2024

  Based on observation, interview, and record review, the facility failed to ensure proper handwashing for 2 of 2 dining observations. This had the potential to affect 53 of 53 residents who ate meals from the kitchen. Findings include: During a dining observation on 7/31/24 the following was observed: a. At 11:41 a.m., [NAME] 5 was observed washing his hands at the sink in the dining room, he turned off the faucet with his bare hands, without using a paper towel to turn off the water. He then proceeded back into the kitchen. b. At 11:43 a.m., [NAME] 5 was observed washing his hands at the sink in the dining room, he turned off the faucet with his bare hands, without using a paper towel to turn off the water. […]

• No harm, potential for more than minimal, patternF655Apr 27, 2022

  Based on record review and interview, the facility failed to ensure a copy of the baseline care plan was provided to the residents or their representatives (Residents 39, 58, 32, 49, 50, and 213), and failed to follow their facility policy for holding the resident's initial care plan (Resident First) meetings in a timely manner (Residents 39 and 58). Findings include: 1. Resident 39's record was reviewed on 4/22/22 at 2:12 p.m. The profile indicated the resident had been admitted to the facility on [DATE]. A baseline care plan had been completed on 2/28/22 and lacked documentation of a copy of the baseline care plan being provided to resident or their representative. Care plan documentation indicated the resident's initial Resident First Meeting had been held on 3/23/22. 2. […]

• No harm, potential for more than minimal, isolatedF578Nov 21, 2025

  Based on record review and interview, the facility failed to ensure a resident had their predetermined advance directive preference of Do Not Resuscitate (DNR) when she was changed to a full code status upon admission for 1 of 3 residents reviewed for advanced directives (Resident 69). Findings include:On 11/18/25 at 12:02 p.m., Resident 69's record was reviewed. She admitted to the facility on [DATE]. Her comprehensive care plan indicated she had diagnoses which included, but was not limited to, Parkinson's disease (a progressive, incurable neurological disorder that affects movement, causing symptoms like tremors, slowness of movement and rigidity caused by loss of brain cells).Upon her admission she had a living will, dated 2/27/1992, which indicated, she did not want her life to be… […]

• No harm, potential for more than minimal, isolatedF657Nov 21, 2025

  Based on record review and interview, the facility failed to ensure that a resident's code status matched the comprehensive care plan for 1 of 5 residents reviewed for advance directives (Resident 12). Findings include: On 11/19/25 at 10:54 a.m., Resident 12's record was reviewed. She had the following diagnoses which included, but were not limited to, asphasia (difficulty speaking), dysphagia (difficulty swallowing), cystitis (bladder infection), Parkinson's disease, muscle weakness, and history of falling.Resident 12 had a physician's order for do not resuscitate (DNR) dated 7/22/25.Her comprehensive care plan indicated she desired a full code status dated 7/16/25.On 10/19/25 at 2:00 p.m., the Director of Nursing Services (DNS) provided a copy of the full code care plan.A policy titled,… […]