Inspection Reports for Wellbrooke of Westfield
937 E 186th St, Westfield, IN 46074, United States, IN, 46074
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 5, 2025, found deficiencies related to unauthorized photos taken by staff of residents, which the facility corrected promptly. Earlier inspections showed a pattern of deficiencies primarily involving documentation issues, medication management, oxygen therapy, and life safety code compliance, with some complaints investigated but not substantiated. Prior reports cited problems with emergency preparedness, fire safety, medication handling, resident care documentation, and staff licensing, though enforcement actions such as fines or license suspensions were not listed in the available reports. Complaint investigations were mostly unsubstantiated, except for one substantiated complaint in January 2023 involving abuse and quality of care issues. The facility’s inspection history shows some ongoing challenges with regulatory compliance, but recent corrections and fewer deficiencies in the latest surveys suggest some improvement over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
264% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
98 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458674 at Wellbrooke of Westfield.
Complaint Details
Complaint IN00458674 was investigated and found to have no deficiencies related to the allegations. The unauthorized photo incident involved a terminated employee sending a nude photo of Resident B and a photo including Resident C to another staff member. The facility corrected the issue by 5/8/25 with staff education and policy enforcement.
Findings
No deficiencies related to the complaint allegations were cited; however, unrelated deficiencies were found involving unauthorized photos taken by staff of residents, violating privacy rights. The deficient practice was corrected prior to the survey.
Deficiencies (1)
Facility failed to ensure staff did not take and share unauthorized photos of a resident, violating privacy and confidentiality rights.
Report Facts
Census Bed Type Total: 98
SNF/NF beds: 37
SNF beds: 21
Residential beds: 40
Census Payor Type Total: 58
Medicare residents: 17
Medicaid residents: 21
Other residents: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Qualified Medication Assistant 3 | Terminated Employee | Sent unauthorized photos of residents |
| Certified Nursing Assistant 2 | CNA | Received unauthorized photos and reported incident |
| Executive Director | Executive Director | Interviewed regarding unauthorized photo incident |
| Assistant Director of Nursing | ADON | Interviewed regarding staff photo policy |
| Clinical Support 5 | Clinical Support | Interviewed regarding photo policy and incident |
| Registered Nurse 10 | RN | Interviewed regarding staff phone and photo use policy |
Inspection Report
Life Safety
Census: 60
Capacity: 70
Deficiencies: 1
Date: May 14, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/14/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE).
Deficiencies (1)
Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE) such as electric beds, nebulizers, oxygen concentrators, and air pumps for air mattresses.
Report Facts
Certified beds: 70
Census: 60
Compliance Date: Jun 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Named in relation to the deficiency regarding PCREE testing and maintenance | |
| Assistant Director of Plant Operations | Named in relation to the deficiency regarding PCREE testing and maintenance | |
| Field Maintenance Supervisor | Named in relation to the deficiency regarding PCREE testing and maintenance | |
| Executive Director | Involved in review of findings during exit conference and ongoing compliance monitoring |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on April 28, 2025.
Findings
Wellbrooke of Westfield was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 42
Capacity: 90
Deficiencies: 5
Date: Apr 28, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and the Investigation of Complaint IN00455772.
Complaint Details
Complaint IN00455772 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found to have multiple deficiencies including inaccurate PASARR documentation for residents, insufficient documentation of behavior care plans and care plan meetings, failure to ensure oxygen therapy was administered per physician orders, incomplete medication labeling and narcotic count logs, and incomplete documentation of meal intakes. No deficiencies were cited related to the complaint investigation.
Deficiencies (5)
Failed to ensure the pre-admission screening and resident review (PASARR) was completed accurately for residents 18 and 33.
Failed to ensure sufficient documentation that behavior care plans were prepared by an interdisciplinary team prior to initiation for residents 2, 23, and 42.
Failed to ensure a resident's oxygen concentrator was turned on and failed to obtain a physician's order for oxygen use for residents 15 and 201.
Failed to ensure medication was labeled with resident's name and staff signed narcotic count logs during shift changes in medication carts.
Failed to ensure a resident's medical record was complete and accurately documented related to meal intakes for resident 2.
Report Facts
Survey dates: 6
Census SNF/NF: 48
Census Residential: 42
Total Capacity: 90
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 20
Census Payor Type - Other: 22
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maggie Miller | Executive Director | Signed the report and identified as Executive Director |
| LPN 5 | Interviewed regarding medication labeling and narcotic count logs | |
| LPN 6 | Interviewed regarding oxygen therapy and narcotic count logs | |
| Director of Nursing | Director of Nursing | Interviewed regarding PASARR and care plan documentation |
| Social Service Director | Social Service Director | Interviewed regarding PASARR and care plan meetings |
| Clinical Support 3 | Interviewed regarding care plan revisions and policies | |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding oxygen orders and documentation |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 88
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440352.
Complaint Details
Complaint IN00440352 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00440352 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF beds: 29
Census SNF/NF beds: 21
Census Residential beds: 38
Total Census: 50
Total Capacity: 88
Medicare Census: 16
Medicaid Census: 21
Other Payor Census: 13
Inspection Report
Re-Inspection
Census: 53
Capacity: 70
Deficiencies: 0
Date: Jun 10, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 04/23/24.
Findings
At this PSR survey, Wellbrooke of Westfield was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 70
Census: 53
Inspection Report
Life Safety
Census: 54
Capacity: 70
Deficiencies: 9
Date: Apr 23, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements, including failure to conduct required 36-month continuous emergency generator testing, failure to maintain fire alarm system emergency control functions and testing, deficiencies in life safety code related to egress door locking, hazardous area enclosures, sprinkler system maintenance, portable fire extinguisher installation, and boiler inspection certificates.
Deficiencies (9)
Failed to implement emergency power system inspection, testing, and maintenance requirements; 36-month continuous 4-hour emergency generator testing not performed.
Failed to ensure means of egress door was readily accessible; exit door keypad code not posted.
Failed to ensure hazardous areas such as combustible storage rooms and soiled linen/trash rooms were separated by smoke resistant partitions and doors.
Failed to ensure fire alarm system emergency control functions were maintained and smoke damper testing documentation was not available.
Failed to maintain fire alarm system with required semi-annual visual inspections and accurate time and date on control panel.
Failed to maintain ceiling construction in smoke barrier; gap around sprinkler head in Data Room.
Failed to ensure portable fire extinguishers were properly installed and secured.
Failed to maintain current inspection certificates for all boilers requiring state inspection.
Failed to document 36-month continuous 4-hour emergency generator testing as required by NFPA standards.
Report Facts
Certified beds: 70
Census: 54
Emergency generator rating: 200
Emergency generator load test duration: 90
Required emergency generator test duration: 240
Boilers without current inspection certificates: 4
Portable fire extinguishers improperly installed: 2
Hazardous areas not properly enclosed: 3
Fire alarm semi-annual inspection missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maggie Miller | Executive Director | Named as Executive Director involved in record review and exit conference |
| Director of Plant Operations | Named in multiple findings related to emergency power, fire alarm, life safety, and corrective actions | |
| Facilities Management Support | Involved in record review, observations, and interviews related to deficiencies |
Inspection Report
Recertification
Census: 39
Capacity: 39
Deficiencies: 11
Date: Apr 4, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of two nursing home complaints.
Complaint Details
Complaint IN00428770 and IN00428393 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints investigated. Several deficiencies were cited including issues with Medicaid/Medicare coverage notices, transfer/discharge notifications, quality of care including medication administration and bowel monitoring, respiratory care, nurse staffing posting, unnecessary drug use, psychotropic medication monitoring, staff licensing, infection control, and medication storage.
Deficiencies (11)
Failed to ensure Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage options were documented and chosen correctly for residents.
Failed to notify the Office of the State Long-Term Care Ombudsman when a resident was hospitalized.
Failed to ensure physician's order was transcribed correctly to the Medication Administration Record and failed to monitor and document bowel movements.
Failed to ensure oxygen was administered according to an active physician's order and failed to label oxygen tubing.
Failed to post current nurse staffing information daily at the beginning of each shift.
Failed to ensure a lab was obtained according to physician's order prior to giving an antibiotic.
Failed to ensure correct diagnosis was added to an antipsychotic order and to monitor for psychotic symptoms.
Failed to ensure a staff member had a valid nursing license.
Failed to store medications at the proper temperature in medication refrigerator.
Failed to ensure medications were handled in a sanitary manner and failed to ensure staff transported clean linen/gowns properly.
Failed to complete a semi-annual evaluation for a resident.
Report Facts
Census: 39
Facility Capacity: 39
Survey Dates: 7
Deficiency Severity Count: 9
Deficiency Severity Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 9 | Registered Nurse | Worked multiple shifts without a valid Indiana nursing license |
| RN 3 | Registered Nurse | Observed handling medication with bare hands |
| Social Services Director | Interviewed regarding Medicaid/Medicare notices and psychotropic medication monitoring | |
| Clinical Support Nurse | Provided multiple interviews and policies related to deficiencies | |
| Executive Director | Signed report and interviewed regarding nurse staffing posting and licensing | |
| Housekeeper 5 | Observed transporting clean linen improperly | |
| CNA 4 | Certified Nursing Assistant | Observed transporting clean linen improperly |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure survey.
Findings
Wellbrooke of Westfield was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 2
Date: Nov 9, 2023
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00419511 and Residential Complaints IN00414987, IN00402052, and IN00401982.
Complaint Details
The investigation involved four complaints (IN00419511, IN00414987, IN00402052, IN00401982). No deficiencies related to the allegations were cited for any of these complaints. The investigation revealed unrelated deficiencies involving medication misappropriation by a Registered Nurse (RN 2) who was terminated for gross misconduct.
Findings
No deficiencies related to the allegations of the complaints were cited. However, unrelated deficiencies were cited involving misappropriation of medications by a Registered Nurse who removed discontinued medications without consent and ordered medications without authorization for 5 residents. The deficient practice was corrected prior to the survey.
Deficiencies (2)
Facility failed to protect residents from misappropriation of property, specifically medications, when a Registered Nurse removed discontinued medications without consent and ordered medications without authorization for 5 residents.
Facility failed to maintain a record of disposition/return of unused and discontinued medications to the pharmacy and failed to ensure a licensed physician or nurse practitioner authorized or prescribed medications for 5 residents.
Report Facts
Census Bed Type Total: 78
Residents reviewed for misappropriation: 5
Medication doses received by Resident 2: 18
Medication doses refused by Resident 2: 1
Medication doses missed by Resident 2: 2
Medication tablets diverted for Resident 3: 30
Medication doses received by Resident 3: 13
Medication doses received by Resident 4: 11
Medication doses prescribed for Resident 4: 10
Medication doses received by Resident 5: 0
Medication doses received by Resident 6: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Named in findings related to medication misappropriation and unauthorized medication ordering; terminated for gross misconduct. |
| Nurse Practitioner 3 | Nurse Practitioner | Interviewed and confirmed medications were not authorized or ordered by licensed providers. |
| Corporate Support Nurse | Interviewed multiple times regarding medication diversion and facility practices. | |
| Executive Director | Provided facility policies and information about the investigation. |
Inspection Report
Life Safety
Census: 68
Capacity: 70
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related NFPA 101 standards.
Findings
The facility was found in compliance with Emergency Preparedness and Life Safety Code requirements overall, but a deficiency was cited for failure to properly secure and segregate five oxygen cylinders in the oxygen storage and transfilling room, which could affect residents, staff, and visitors.
Deficiencies (1)
Failed to ensure 5 of 5 cylinders of nonflammable gases such as oxygen were properly secured from falling and segregated between full and empty cylinders in the oxygen storage and transfilling room.
Report Facts
Certified beds: 70
Census: 68
Oxygen cylinders improperly secured: 5
Residents potentially affected: 14
Staff potentially affected: 4
Visitors potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roger Piotrowicz | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Plant Operations | Named in relation to the oxygen cylinder deficiency and education on corrective actions |
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 14, 2023
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and health care occupancy regulations.
Findings
WellBrooke of Westfield was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code from Fire, and applicable state and national fire safety regulations.
Inspection Report
Recertification
Census: 79
Deficiencies: 16
Date: Jan 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Nursing Home Complaint IN00394060.
Complaint Details
Complaint IN00394060 was substantiated. Federal/State deficiencies related to the allegations are cited at F677.
Findings
The facility was found to have multiple deficiencies including failure to assess residents for self-administration of medications, failure to prevent abuse and neglect, failure to provide bed hold policy notices, failure to provide timely incontinence care, failure to provide quality care for residents with change of condition, pressure ulcers, mobility assistance, respiratory care, pain management, bed rail assessments, medication storage, food safety, insulin storage, infection control, and COVID-19 vaccination compliance.
Deficiencies (16)
Failed to ensure residents had been assessed for self-administration of medications before leaving medications unattended for 2 residents.
Failed to ensure all residents were free from abuse, including physical abuse or intimidation for 2 residents alleging such incidents.
Failed to ensure alleged violations of abuse were reported to the State Survey Agency as required for 2 allegations of abuse.
Failed to ensure the bed hold policy was provided to residents who transferred to the hospital or within 24 hours of transfer for 4 residents.
Failed to timely provide incontinence care to a dependent resident.
Failed to provide necessary care and services for a resident who had a change of condition and required hospitalization.
Failed to provide treatment and services to adequately assess for pressure ulcers and to ensure physician's orders were followed for 1 resident.
Failed to ensure a resident received assistance with mobility who was dependent on staff for ambulation.
Failed to store nebulizer masks/equipment in a sanitary manner and failed to ensure cautionary and safety signs indicating oxygen use were posted for 3 residents.
Failed to ensure all drugs and biologicals were stored in accordance with professional standards in medication and treatment carts.
Failed to ensure masks were worn correctly in the kitchen, failed to keep boxes off the floor of the freezer, failed to ensure foods were kept closed and labeled with open dates, and failed to ensure dishwasher reached appropriate wash temperatures.
Failed to ensure insulin pen was labeled with an open date when opened for 1 resident.
Failed to maintain an infection prevention and control program to help prevent transmission of infections when staff failed to wear face masks correctly while interacting with residents and in the kitchen.
Failed to ensure staff were fully vaccinated or had approved exemptions for COVID-19 vaccination for 1 staff member.
Failed to ensure resident care equipment was kept in a sanitary condition and clean linens were provided for 1 hallway and 1 resident.
Failed to ensure residents had a self-administration assessment for medications and failed to ensure a resident had an order for a medication for 2 residents.
Report Facts
Survey dates: 6
Census Bed Type: 79
Census Payor Type: 51
Deficiencies cited: 2
Deficiencies cited: 2
Deficiencies cited: 4
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 3
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Named in medication self-administration finding |
| LPN 10 | Licensed Practical Nurse | Named in respiratory care and infection control findings |
| RN 18 | Registered Nurse | Named in abuse allegation involving throwing items at resident |
| CNA 23 | Certified Nursing Assistant | Named in abuse allegation and COVID-19 vaccination noncompliance |
| Director of Nursing | Director of Nursing Services | Named in multiple interviews regarding medication self-administration and abuse investigations |
| Executive Director | Executive Director | Named in abuse investigation and corrective action |
| Therapy Director | Therapy Director | Named in abuse investigation |
| Speech Therapist 17 | Speech Therapist | Named in infection control mask wearing observation |
| Dietary Manager | Dietary Manager | Named in food safety and mask wearing observations |
| LPN 3 | Licensed Practical Nurse | Named in resident lift equipment cleaning observation |
| CNA 13 | Certified Nursing Assistant | Named in treatment cart observation |
| RN 7 | Registered Nurse | Named in medication cart observation |
| LPN 14 | Licensed Practical Nurse | Named in medication cart observation |
| Dietary Aide 16 | Dietary Aide | Named in dishwasher and mask wearing observations |
| Corporate Support Nurse | Corporate Support Nurse | Named in multiple interviews and policy provision |
| Director of Health Services | Director of Health Services | Named in multiple interviews and corrective action plans |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in bed rail assessment interview |
| LPN 12 | Registered Nurse | Named in change of condition interview |
| RN 6 | Registered Nurse | Named in change of condition interview |
| PT 8 | Physical Therapist | Named in change of condition interview |
| Social Worker 22 | Social Worker | Named in bed hold policy interview |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
Paper compliance review related to the Recertification and State Licensure survey and the Investigation of Complaint IN00394060 completed on January 30, 2023.
Complaint Details
Investigation of Complaint IN00394060 was included in the review.
Findings
Wellbrooke of Westfield was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure survey and the Investigation of Complaint IN00394060.
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