Wellbrooke of South Bend

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 25, 2025

  Based on observation, interview and record review, the facility failed to ensure a CNA (Certified Nursing Aide) followed the resident's comprehensive care plan regarding fall prevention for 1 of 3 residents reviewed for falls. (Resident B) This resulted in the resident falling to the floor, fracturing both femurs (thigh bones) and required surgical repair of the fractures and hospitalization after the staff member left the resident seated on the side of their bed, without supervision. (Resident B) Finding includes: A facility self-reported incident #300, dated 5/30/25 at 10:39 A.M., indicated Resident B was .sitting on bed and attempted to transfer unassisted and fell on her side. […]

• No harm, potential for more than minimal, widespreadF812Feb 20, 2024

  Based on observation, record review, and interview, the facility failed to store food under sanitary conditions, related to foods not tightly sealed, outdated foods, and dirty kitchen equipment, for 1 of 1 kitchen observed. This had the potential to affect all residents who resided in the facility and received food from this dietary kitchen. Findings include: On 2/13/2023 at 9:45 A.M., a kitchen tour was conducted with the Dietary Manager (DM). The following was observed in the walk-in cooler: - A bag of carrots in the walk-in cooler with a use by date of 2/9/2024. - A bag of chopped onions with a use by date of 2/11/2024. - A block of cream cheese not sealed tightly. - A bag of mashed sweet potatoes not sealed tightly. […]

• No harm, potential for more than minimal, widespreadF812Dec 15, 2022

  Based on observation and interview, the facility failed to ensure kitchen utensils, pots, colanders and dishes were covered and inverted, extra powder thickener was not poured back into its origional container, and clean thermometers were stored in a sanitary [NAME] until reuse after cleaning with probe wipe, this effected 44 of 44 residents who received their meals from the kitchen. Findings include: 1. During an observation, on 12/9/2022 at 10:43 A.M., Cook 4 over filled the measuring cup with thickener and poured some of it back into the container. During an interview, on 12/9/2022 at 10:49 A.M., Cook 4 indicated she should not have poured it back in the container. 2. […]

• No harm, potential for more than minimal, patternF550Feb 6, 2025

  Based on interview and record review, the facility failed to have a process for residents to file a grievance anonymously. This had the potential to affect 54 of 54 residents who resided in the facility. Finding includes: During a Resident Council meeting on 1/30/2025 at 10:29 A.M., 8 out of 8 residents did not know how to file a grievance anonymously. On 1/30/2025 at 11:01 A.M., the Executive Director (ED) indicated the facility used an application (app) to allow residents to file a grievance. The app to file a grievance was only accessible on facility computers and tablets. If a resident wanted to file a grievance, the resident had to tell a staff member so the staff member could open the app and give the resident the electronic device. […]

• No harm, potential for more than minimal, patternF812Feb 6, 2025

  Based on observation and interview, the facility failed to serve food in a sanitary manner for 1 of 3 dining rooms observed. This had the potential to affect 9 of 9 residents ate in the dining room. Finding includes: During an observation and interview, on 1/30/2025 at 11:29 A.M., Dietary Aide 4 carried two different residents' plates with her thumb on the eating surface of plate. The dietary aide indicated the residents' plates should have been carried from the bottom surface. […]