Cycle 1
Health 2025-02-06 · Fire 2025-02-06
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
South Bend, IN
Wellbrooke Of South Bend
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
52565 State Road 933, South Bend, IN
(574) 247-7044
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2014-09-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.02
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.84
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
3.66
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
538
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0213
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 21.74% · Performance 16.74% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
8.64
Baseline 7.82% · Performance 5.25% · Measure score 8.64 · Achievement 8.64 · Improvement 8.59
Total nurse turnover
6.14
Baseline 41.54% · Performance 38.60% · Measure score 6.14 · Achievement 6.14 · Improvement 1.26
Adjusted total nurse staffing
2.45
Baseline 3.47 hours · Performance 3.77 hours · Measure score 2.45 · Achievement 2.45 · Improvement 0.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.18% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 247 · Observed rate 10.12% · Lower 95% interval 8.27% |
| Discharge to community | 62.4% |
50.57%
11.8 pts better
|
Better than the National Rate · Eligible stays 245 · Observed rate 60.82% · Lower 95% interval 56.28% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 219 · Denominator 219 |
| Falls with major injury | 0.46% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 219 |
| Discharge self-care score | 72.56% |
53.69%
18.9 pts better
|
Numerator 119 · Denominator 164 |
| Discharge mobility score | 62.2% |
50.94%
11.3 pts better
|
Numerator 102 · Denominator 164 |
| Pressure ulcers or injuries, new or worsened | 0.46% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 219 · Adjusted rate 0.37% |
| Healthcare-associated infections requiring hospitalization | 5.25% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 2.52% · Lower 95% interval 3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 95 |
| Staff flu vaccination coverage | 41.79% |
42%
0.2 pts worse
|
Numerator 56 · Denominator 134 |
| Discharge function score | 75.61% |
56.45%
19.2 pts better
|
Numerator 124 · Denominator 164 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 76 · Denominator 76 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 112 · Denominator 112 |
| Resident COVID-19 vaccinations up to date | 32.26% |
25.2%
7.1 pts better
|
Numerator 40 · Denominator 124 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.6
1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 13.0% |
3.8%
9.2 pts worse
|
3.3%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 14.3% · Q3 13.6% · Q4 14.3% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
24.6%
19 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · Q3 4.5% · Q4 9.5% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
5.6%
4.1 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
23.5%
6.1 pts better
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.8% |
14.8%
18 pts worse
|
16.7%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
11.7%
5.1 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
24.2%
2.4 pts better
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.1%
1.9 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 9.3% · Q4 9.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
81.6%
15.6 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.4% · Q3 96.3% · Q4 95.6% · 4Q avg 97.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
10.5%
3.2 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 13.1% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.6% · Q3 0.8% · Q4 1.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
79.0%
20 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
22.4%
1.3 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 22.8% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-20 · Fire 2024-02-20
3 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-12-15 · Fire 2022-12-15
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-02-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-02-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-24
E · Potential for more than minimal harm
2025-02-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-01
E · Potential for more than minimal harm
2025-02-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-27
F · Potential for more than minimal harm
2024-02-20
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-02-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-02-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-07
F · Potential for more than minimal harm
2024-02-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-02-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-02-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-29
C · Minimal harm
2024-02-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-29
F · Potential for more than minimal harm
2022-12-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-14
E · Potential for more than minimal harm
2022-12-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-14
E · Potential for more than minimal harm
2022-12-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-14
E · Potential for more than minimal harm
2022-12-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-14
B · Minimal harm
2022-12-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-19
G · Actual harm
2025-06-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-06-25
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-07-02
E · Potential for more than minimal harm
2025-02-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-02-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-06
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
F · Potential for more than minimal harm
2024-02-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-02-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-12-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-12-15
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-12-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-12-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-11
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Dupre, Matthew
Operational/Managerial Control · Individual
Lcs South Bend LLC
Operational/Managerial Control · Organization
Long, Steven
Operational/Managerial Control · Individual
Long, Steven
Corporate Officer · Individual
Steinhaus, Karl
Operational/Managerial Control · Individual
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Holy Cross Village At Notre Dame Inc
Notre Dame, IN
5-star overall rating with 4-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
Healthwin Health & Rehabilitation
South Bend, IN
1-star overall rating with 1-star inspections with $29,744 in total fines with 15 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Milton Home, The
South Bend, IN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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