Wellbrooke of Wabash

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Nov 24, 2021

  Based on observation, interview and record review, the facility failed to protect a cognitively impaired resident (Resident B) from a resident (Resident C) with sexually aggressive behaviors. This deficient practice resulted in a non-consensual sexual act with a cognitively impaired resident for 1 of 3 residents reviewed for abuse. (Resident B) The immediate jeopardy began on 11/16/21 when Resident C was observed to have his pajama pants folded down with his penis exposed, and Resident C's was in Resident B's mouth. The Administrator was notified of the immediate jeopardy on 11/23/21 at 4:29 p.m. […]

• Actual harm, isolatedF760Jul 21, 2022

  Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for 1 of 4 residents reviewed for medication administration. This deficient practice resulted in a resident being given the wrong mediations and being sent to the emergency room then admitted to the hospital for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: An investigation into the medication error was provided by the Administrator on 7/20/22 at 10:52 a.m. Review of the facility investigation included the following: a. A statement by LPN 1, dated 7/8/22, indicated she administered the wrong medication at 8:57 a.m. She immediately recognized the error and reported to the Nurse Practitioner (NP). […]

• Actual harm, isolatedF689Feb 9, 2022

  A. Based on record review and interview, the failed to provide adequate supervision to prevent further falls for 1 of 8 residents reviewed for falls (Resident 43). This deficient practice resulted in Resident 43 sustaining a femur fracture. B. Based on observation, interview, and record review the facility failed provide adequate supervision to a resident with a known diagnosis of dysphagia for 1 of 3 residents reviewed for dysphagia (Resident 150). Findings include: 1. During an observation on 2/1/22 at 9:36 a.m., Resident 43 was sitting in a wheel-chair in the common area across from the nurses' station, she had a cast to right wrist that extended to the top of her hand, she mumbled help me Jesus and oh my God and some nonsensical verbalizations. […]

• No harm, potential for more than minimal, widespreadF812Jan 14, 2026

  Based on observation and interview, the facility failed to store and prepare food under safe and sanitary conditions related to kitchen equipment and storage. This deficient practice had the potential to affect 92 of 92 residents who received food from the facility kitchen. Findings include:During a kitchen observation on 1/8/26 at 9:58 a.m., accompanied by the Dietary Manager, the following was observed:Upon entering the kitchen, numerous food splatters ranged from brown, black and red in color were on the floor in front of the doorway.Brown and black grease buildup was noted to the left side of the stove on the side of the steamer. […]

• No harm, potential for more than minimal, patternF880Feb 9, 2022

  Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19 by failing to ensure personal protective equipment (PPE) was applied appropriately for 3 of 3 random observations of staff (CNA 42, QMA 44, MDS Coordinator, CNA 39, SSD). Findings include: During a random observation, on 2/01/22 at 1:32 p.m., CNA 42, prior to entering resident room [ROOM NUMBER] which signage indicated required TBP, applied gown, N95 mask over surgical mask, and gloves. During an interview, at the time of the observation, CNA 42 indicated the facility told him he could put the N95 over his surgical mask then he did not have to remove his surgical mask. […]