WELLBROOKE OF SOUTH BEND Nursing Home


WELLBROOKE OF SOUTH BEND (CCN: 155824) is a For profit - Corporation facility located in SOUTH BEND, IN (46637). The facility has an overall rating of 4/5, health inspection rating of 3/5, and a staffing rating of 5/5. It offers 70 certified beds and maintains an average of 45.4 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.25402 total hours per resident per day. It has been certified since September 9, 2014 and the last listed health inspection was on December 15, 2022, The facility is located in St. Joseph county and provides senior and nursing home care.

WELLBROOKE OF SOUTH BEND Summary


Patient Ratings
Please rate how you felt your loved one or yourself have been treated at Wellbrooke Of South Bend below to help others make a more informed decision. Thank you.
Current Rating: Loading...

Provider Name: WELLBROOKE OF SOUTH BEND

Address: 52565 STATE ROAD 933, SOUTH BEND, IN 46637

Phone: (574) 247-7044

County: St. Joseph (700)

Ownership Type: For profit - Corporation

Certified Beds: 70

Average Residents Per Day: 45.4 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: HANCOCK REGIONAL HOSPITAL

First Approved Date: September 9, 2014

Affiliated Entity: TRILOGY HEALTH SERVICES (524)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Both

Sprinkler System Status: Yes

Overall Rating: 4 ()

Health Inspection Rating: 3 ()

QM Rating: 3 ()

Long Stay QM Rating: 3 ()

Short Stay QM Rating: 3 ()

Staffing Rating: 5 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.42321, LPN Staff Hours Per Day: 0.7689, RN Staff Hours Per Day: 1.0618, Licensed Staff Hours Per Day: 1.8308

Total Nurse Staff Hours Per Day, per resident: 4.25402

Weekend Nurse Staff Hours: 3.69592, Weekend RN Staff Hours: 0.8508

PT Staff Hours Per Day, per resident: 0.0913

Nurse Staff Turnover: 36.2, Nurse Turnover Note:

RN Turnover: 0.0, RN Turnover Note:

Admin Left Number: , Admin Turnover Note: 6

Case Mix Nurse Aide Hours Per Day, per resident: 2.1325, Case Mix LPN Hours Per Day: 0.7335, Case Mix RN Hours Per Day: 0.3614

Adjusted Nurse Aide Hours Per Day, per resident: 2.31487, Adjusted LPN Hours Per Day: 0.7735, Adjusted RN Hours Per Day: 1.1070

Total Adjusted Nurse Hours Per Day, per resident: 4.15445

Adjusted Weekend Nurse Hours Per Day, per resident: 3.60941

Health Survey Dates and Scores: Cycle 1: 2022-12-15 (Score: 32), Cycle 2: 2019-04-29 (Score: 24), Cycle 3: 2018-02-20 (Score: 44)

Total Weighted Health Score: 31.333

Reported Incidents: 2, Substantiated Complaints: 2

Infection Control Citations: 2

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 9750.00, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 52565 STATE ROAD 933,SOUTH BEND,IN,46637 (41.7101, -86.250)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2022-12-15

Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-11

Citation on 2022-12-15

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-11

Citation on 2022-12-15

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-11

Citation on 2022-12-15

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-11

Citation on 2022-12-15

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-11

Citation on 2022-03-22

Type: Health, Deficiency: Ensure staff are vaccinated for COVID-19

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-29

Citation on 2019-04-29

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-18

Citation on 2019-04-29

Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-18

Citation on 2019-04-29

Type: Health, Deficiency: Implement a program that monitors antibiotic use.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-18

Citation on 2019-04-29

Type: Health, Deficiency: Develop and implement policies and procedures for flu and pneumonia vaccinations.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-18

Citation on 2021-12-06

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-23

Citation on 2021-03-02

Type: Health, Deficiency: Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-03-15

Citation on 2018-02-20

Type: Health, Deficiency: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-22

Citation on 2018-02-20

Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-22

Citation on 2018-02-20

Type: Health, Deficiency: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-22

Citation on 2018-02-20

Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-22

Citation on 2018-02-20

Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-22

Citation on 2018-02-20

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-22


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-01-25

Type: Fire Safety, Tag: 0321, Version: New

Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-02-14

Citation on 2023-01-25

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-02-14

Citation on 2023-01-25

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-02-14

Citation on 2023-01-25

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-02-14

Citation on 2023-01-25

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-02-14

Citation on 2019-06-13

Type: Fire Safety, Tag: 0753, Version: New

Description: Have restrictions on the use of highly flammable decorations.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-06-28

Citation on 2019-06-13

Type: Fire Safety, Tag: 0914, Version: New

Description: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-06-28

Citation on 2019-06-13

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-06-28

Citation on 2019-06-13

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-06-28

Citation on 2018-03-27

Type: Fire Safety, Tag: 0007, Version: New

Description: Address patient/client population and determine types of services needed.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-06-04

Citation on 2018-03-27

Type: Fire Safety, Tag: 0023, Version: New

Description: Establish policies and procedures for medical documentation.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0024, Version: New

Description: Establish policies and procedures for volunteers.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0034, Version: New

Description: Provide a means of sharing information on occupancy/needs.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0035, Version: New

Description: Provide family notifications of emergency plan.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-06-04

Citation on 2018-03-27

Type: Fire Safety, Tag: 0211, Version: New

Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-06-04

Citation on 2018-03-27

Type: Fire Safety, Tag: 0222, Version: New

Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0291, Version: New

Description: Install emergency lighting that can last at least 1 1/2 hours.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0321, Version: New

Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-06-04

Citation on 2018-03-27

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0531, Version: New

Description: Have elevators that firefighters can control in the event of a fire.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26

Citation on 2018-03-27

Type: Fire Safety, Tag: 0927, Version: New

Description: Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-26