Deficiency Records for Wellbrooke of South Bend
Updated as of July 01, 2018
This is not the most recent data for Wellbrooke of South Bend. For the most recent information, click here.
A list of the most recent deficiencies for Wellbrooke of South Bend. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-03-27 | 2018-06-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-03-27 | 2018-06-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-27 | 2018-06-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-27 | 2018-06-04 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| 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. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| 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. | Health | 2018-02-20 | 2018-03-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-02-20 | 2018-03-22 | N |
| 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. | Health | 2018-02-20 | 2018-03-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-02-20 | 2018-03-22 | N |
| 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 ne | Health | 2018-02-20 | 2018-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-20 | 2018-03-22 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-21 | 2017-10-19 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-01-17 | 2017-02-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-01-17 | 2017-02-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-01-17 | 2017-02-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-01-17 | 2017-02-16 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2017-01-17 | 2017-02-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-01-17 | 2017-02-16 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-12-21 | 2017-01-20 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-12-21 | 2017-01-20 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-12-21 | 2017-01-20 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-12-21 | 2017-01-20 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-21 | 2017-01-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-21 | 2017-01-20 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-12-21 | 2017-01-20 | Y |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-11-17 | 2015-12-17 | N |
| Horizontal exits. | Fire Safety | 2015-11-17 | 2015-12-17 | N |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2015-11-17 | 2015-12-17 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-11-17 | 2015-12-17 | N |
| Properly protected cooking facilities. | Fire Safety | 2015-11-17 | 2015-12-17 | N |
| Have other fire safety features required by fire safety codes. | Fire Safety | 2015-11-17 | 2015-12-17 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-11-17 | 2015-12-17 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2015-11-12 | 2015-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-11-12 | 2015-12-10 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2015-11-12 | 2015-12-10 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-11-12 | 2015-12-10 | N |
| Provide food in a way that meets a resident's needs. | Health | 2015-11-12 | 2015-12-10 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-11-12 | 2015-12-10 | N |
