Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellbrooke Of Avon during CMS and state inspections, most recent first.
A resident with HF and HTN received carvedilol and clonidine even when HR and SBP were outside ordered hold parameters, and an RN stated the meds should have been held. The facility also kept a resident's Systane eye drops at the bedside without a documented self-administration assessment or order allowing self-administration.
An LPN was observed with medication carts containing opened nasal spray, saline, and eye ointment without dates showing when they were opened. An unopened bottle of latanoprost eye drops that required refrigeration until opened was also found in the cart. The LPN stated there were no open dates on the medications.
Infection control practices were not followed for a resident with a central line and a resident with a suprapubic catheter. Staff did not have EBP signage or PPE available for either resident at the time of care, and CNAs provided high-contact ADL care to the resident with the suprapubic catheter without PPE. The resident with the central line also had a dressing that was not changed per the facility’s policy.
Freezer equipment and associated systems were not maintained in proper working order. Surveyors observed an apparent compressor leak with frozen droplets and ice cycles on freezer piping, and ice buildup had developed on cardboard boxes holding frozen bread in opened plastic wrap. On a later observation, new freezing droplets were still present on the freezer ceiling and wall seal. Staff stated the ice buildup had not been reported, and the plant operations director said staff should monitor the unit for ice buildup.
The facility failed to ensure timely entry of medical provider notes into residents' medical records, affecting six residents. Late entries, some over three business days, included important medical recommendations and orders. Interviews revealed a lack of specific timelines in facility policy, with expectations for notes to be available within three business days, while a Nurse Practitioner aimed for 48-hour accessibility.
A facility failed to create a person-centered care plan for a resident with recurrent UTIs, despite the resident experiencing seven UTIs in a year. The resident's medical history included chronic kidney disease and sepsis. The facility's policy required chronic issues to be addressed with a comprehensive care plan, but only a general bowel and bladder care plan was in place.
The facility failed to provide effective pressure ulcer care and accurate documentation for two residents. One resident had a stage II ulcer with delayed documentation and continued treatment orders despite resolution. Another resident's records lacked documentation of a new wound, and treatments continued without evidence of an open area. Facility policy on wound documentation was not followed.
A resident with a history of falls and vision impairment was at risk due to a loose rubber threshold in her bathroom, which was not promptly repaired. Despite her fear of falling and the presence of an immobilizer boot, the hazard remained unaddressed for several days, as confirmed by staff observations and interviews.
The facility failed to date an insulin pen when opened, as observed during a review of a medication cart. An insulin pen for a resident was found without a date indicating when it was opened. The ADNS acknowledged that a nurse likely removed the pen from the refrigerator the previous night and failed to date it, contrary to the facility's policy requiring opened medications to be dated.
A resident with hemiplegia and hemiparesis following a stroke did not receive showers according to their preference of twice weekly, as documented in their care profile. Over a four-month period, the resident received only 16 showers, contrary to the facility's policy and the resident's stated preference. The DON indicated potential safety concerns but could not confirm if two-person assistance was required.
A facility failed to ensure a nurse aide was competent in using a mechanical lift, leading to an incident where a resident fell and was injured. The resident, dependent on staff for mobility, was not properly secured during a transfer, resulting in a fall. The aide did not follow the facility's guideline of using two staff members for such transfers. Further investigation revealed similar issues with other residents, including incorrect lift pad sizing and inconsistent adherence to transfer protocols.
Failure to Hold Ordered BP Medications and Assess Self-Administration of Bedside Eye Drops
Penalty
Summary
The facility failed to hold ordered blood pressure medications for a resident with heart failure and hypertension when the resident's vital signs were outside the prescribed parameters. Resident 9 had physician orders for carvedilol 12.5 mg twice daily to be held if heart rate was less than 60 or systolic blood pressure was less than 100, and clonidine 0.1 mg three times daily to be held if systolic blood pressure was less than 140. The MAR showed carvedilol was given when the resident's heart rate was 59 on 2/4/26 and 2/17/26, and clonidine was given on multiple occasions when systolic blood pressure readings were below the ordered hold parameter, including 109/65, 138/66, 139/78, 101/63, and 128/78. RN 3 stated the medications should have been held due to the blood pressure readings, while the DON stated there was no policy for parameters and that staff followed the physician's orders. The facility also failed to properly assess a resident's ability to self-administer eye drops before keeping them at the bedside. Resident 96, a rehab resident with chronic respiratory failure, was observed with an open bottle of Systane eye drops on the nightstand and an unopened box of the same eye drops on the bedside table. The resident stated the drops were hers, that she used them because her eyes got dry often, and that she had kept them at her bedside since arrival. Review of the record found no medication self-administration assessment for the eye drops and no order allowing self-administration of Systane eye drops. The DON and ED later indicated they would look for an assessment, and the DON stated a CNA had come to her before the assessment was requested and that this was when the process of getting the assessment completed began.
Unlabeled Opened Medications and Improper Storage of Refrigerated Eye Drops
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles when medication carts were observed with unlabeled opened medications and an unopened medication requiring refrigeration left in the cart. During observation with an LPN, Resident 6 had fluticasone nasal spray in the cart without a date showing when it was opened, Resident 40 had deep sea premium saline in the cart without an open date, and Resident 61 had retaine PM ointment without an open date. Resident 8 had latanoprost eye drops in the cart; the drops were unopened and the label indicated they were to be refrigerated until opened. When interviewed, the LPN stated there were no dates indicating medications had been opened.
Infection Control and EBP Not Followed for Residents with Indwelling Devices
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident with a central line and a resident with a suprapubic urinary catheter. Resident 2 had a central line in the right chest with a dressing observed on 3/10/26 that was dated 3/9, and there was no EBP signage or PPE outside or inside the room at that time. On 3/11/26, the dressing still appeared unchanged, although an EBP sign and PPE caddy were then present outside the room. Resident 2’s record showed diagnoses including necrotizing fasciitis, gangrene of the left foot, and osteomyelitis, and he had an order for the central line dressing to be changed every 5 days. The record did not contain an order for EBP, and a later progress note documented the dressing change on 3/12/26. Resident 85 was observed with a suprapubic catheter, and two CNAs entered the room to provide care, including washing and changing clothes, without PPE. There was no PPE outside the door and no EBP sign posted, and the CNAs stated they were not sure whether the resident was in EBP because they had not seen a sign and there was no PPE in or outside the room. The resident’s record identified him as a newly admitted resident with diagnoses including sepsis and acute kidney injury, with a physician order for a suprapubic catheter. His care plan directed staff to use PPE during high-contact ADL care such as dressing, hygiene, and transfers.
Freezer Equipment Not Maintained in Proper Working Order
Penalty
Summary
The facility failed to ensure essential kitchen equipment and associated systems were maintained in proper working order to prevent potential contamination for 2 of 2 observations. During an initial kitchen tour on 3/10/26, the freezer was observed with an apparent leak from the compressor system. Frozen droplets and ice cycles were seen on the piping coming in and out of the unit, and drops and mounds of ice had developed on top of cardboard boxes containing frozen bread in opened plastic wrap. The presence of frozen condensation above exposed food items was observed while the Assistant Director of Food Service stated he had not noticed the ice and that kitchen staff had not notified him of any ice buildup. On a follow-up observation on 3/12/26, the pipes had been cleared of ice and reinsulated with new material, but new droplets of freezing ice were observed on the ceiling of the freezer, near the pipe, and along the seal of the freezer wall. During interview, the Corporate Director of Plant Operation stated that ice buildup on freezer compressors was a common effect of the system's routine defrost process and that staff should monitor the unit to prevent ice buildup. He also stated kitchen staff were in the freezer daily and should have identified the ice buildup to notify the Maintenance Director. The Administrator later provided the facility policy, Storage Procedures, dated January 2025, which stated frozen food equipment is routinely cleaned and defrosted and free from garbage and other waste, and freezer doors should be opened as little as possible to prevent fluctuations of storage temperatures.
Delayed Documentation of Medical Provider Notes
Penalty
Summary
The facility failed to ensure that medical providers entered their visit assessments, summaries, and progress notes into the residents' medical records in a timely manner, affecting six out of thirteen residents whose records were reviewed. The deficiency was identified through a pattern of late entries, with some notes being entered more than three business days after the visit. For instance, one resident had a note entered seven days late, which included a new recommendation for a topical anti-inflammatory for knee pain. Another resident had a note entered four days late, which included a new order for antifungal medication and a topical ointment for skin irritation. Interviews with facility staff revealed that there was no specific timeline in the facility policy for signing and uploading documentation, although the expectation was for notes to be available within three business days. A contracted Nurse Practitioner indicated that it was their practice to have notes signed and accessible within 48 hours, but acknowledged the challenge due to the volume of patients and documents. The facility's policy and practice lacked clarity on how documentation was managed if the printed summaries were lost or misplaced, and whether these summaries could temporarily stand in for the signed physician notes until they were uploaded to the electronic health record.
Failure to Develop Care Plan for Recurrent UTIs
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with recurrent urinary tract infections (UTIs). The resident, who had a history of chronic kidney disease and sepsis, experienced seven UTIs over a 12-month period. Despite multiple instances of UTIs confirmed by urine analysis and treated with various antibiotics, the facility did not create a specific care plan addressing the prevention and management of recurrent UTIs. Instead, the resident's care plan only included a general bowel and bladder care plan, which was insufficient for addressing the chronic nature of the resident's condition. The deficiency was identified through a review of the resident's medical records, which showed repeated episodes of UTIs and corresponding treatments. The facility's policy required that ongoing or chronic problems be addressed with a comprehensive care plan, but this was not done for the resident's recurrent UTIs. The lack of a targeted care plan for the resident's condition was a failure to meet the facility's own guidelines for comprehensive care planning.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure appropriate and effective interventions were in place to prevent the development of new pressure ulcers and to maintain accurate documentation for two residents. Resident 16 was observed in a wheelchair with a pressure-reducing cushion and reported soreness that had previously cleared up. Her medical records indicated a stage II pressure ulcer on her coccyx upon admission, but there was a lack of detailed documentation of the wound until 12 days after admission. Despite the wound being resolved in December, treatment orders continued to be administered until March, and the Director of Nursing (DON) was unaware of why the order persisted. Resident 24, a long-term care resident, was observed reclined in bed and reported past pressure ulcer issues. Her medical records showed a new open area on her buttock was noted by a CNA, but there was no documentation of a New Wound/Skin Integrity Event or detailed wound information. Despite the DON's assessment finding no wound, the MD continued to address the area in progress notes, and nurses continued to chart treatments. The records lacked documentation of wound details and resolution. The facility's policy required weekly documentation of wound measurements and conditions, but this was not followed. The policy outlined steps for documenting skin alterations, including completing a wound incident in the electronic health record and recording measurements. However, these procedures were not adhered to, leading to deficiencies in wound care management and documentation for both residents.
Failure to Maintain Safe Environment for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure a safe environment for Resident 99, who had a history of falls and was at risk due to her medical conditions, including homonymous bilateral field defects on the left side, vascular dementia, and a history of falls. During observations, it was noted that the rubber threshold in Resident 99's bathroom was unattached and loose, posing a potential trip hazard. Despite the resident expressing fear of falling, particularly in the bathroom where her vision loss affected her ability to see the hazard, the issue remained unaddressed over several days. Resident 99, who used a wheelchair and had an immobilizer boot on her left foot due to a previous fall, expressed feeling rushed and was instructed by staff not to hold onto grab bars, which increased her anxiety about falling. The resident's medical records confirmed her risk for falls, and her care plan included interventions to ensure the floor was free of hazards. However, the loose rubber threshold was not repaired promptly, as confirmed by a CNA and the Assistant Director of Nursing, who acknowledged the potential trip hazard.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to date medications when opened, as observed during a review of one of the three medication carts. Specifically, an insulin pen for a resident was found in the medication cart without a date indicating when it was opened. During an interview, the Assistant Director of Nursing Services (ADNS) acknowledged that a nurse likely removed the insulin pen from the refrigerator the previous night and failed to date it. The facility's policy, dated November 2018, requires that when the original seal of a manufacturer's container or vial is broken, it must be dated. This policy was provided by the ADNS during the survey.
Failure to Provide Showers According to Resident's Preference
Penalty
Summary
The facility failed to ensure that Resident B received showers according to their bathing preference. Resident B, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke, was documented to have a preference for two showers per week, specifically on Mondays and Wednesdays during the day shift. However, the records indicate that from September 20, 2023, to January 16, 2024, the resident received only 16 showers over a four-month period, which is significantly less than the expected frequency based on their stated preference. During an interview, the Director of Nursing (DON) suggested that the resident might not have received the showers due to safety concerns, although she could not recall if two-person assistance was required for showering. The facility's policy on bathing preferences, which was provided by the DON, states that residents should determine their bathing preferences upon admission and that bathing should occur at least twice a week unless otherwise specified by the resident. This deficiency was identified in relation to a complaint investigation.
Inadequate Competency in Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that a nurse aide was competent in safely transferring a resident using a mechanical lift, resulting in an incident involving Resident B. Resident B, who had a history of hemiplegia and hemiparesis following a stroke, was dependent on staff for mobility and transfers. During an attempt to transfer Resident B using a mechanical lift, the Certified Resident Care Assistant (CRCA) 3 did not secure the wheelchair, causing the resident to slide out and fall, striking her head on the lift device. The CRCA admitted to not locking the wheelchair and was planning to seek assistance after placing the resident in the lift pad, which was against the facility's guidelines that required two staff members for such transfers. The incident report revealed that the CRCA had not received adequate training, as he did not perform a return demonstration of the mechanical lift use after the incident. Interviews with other staff members, including Registered Nurse (RN) 4 and other CRCAs, confirmed that they always used two persons for mechanical lift transfers, highlighting a discrepancy in practice and understanding of the facility's policy. The Director of Nurses (DON) acknowledged the incident and the lack of a physician's order for the use of a mechanical lift for Resident B, which was a part of the deficiency. Further investigation into the facility's practices revealed similar issues with other residents requiring mechanical lift transfers. Resident D was found using an incorrectly sized lift pad, and the staff involved were not aware of the proper sizing, which was indicated by the color trim on the lift pad. The Assistant Director of Nursing (ADON) had to intervene and instruct the staff on the correct procedures. The facility's policy and manufacturer guidelines recommended two assistants for mechanical lift transfers, but the facility's practice did not consistently adhere to this, contributing to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brooke Knoll Village | 0.7 mi | ★★★★★ | 10 | 0 |
| Westside Retirement Village | 1.2 mi | ★★★★★ | 31 | 0 |
| Eagle Valley Meadows | 2.8 mi | ★★★★★ | 3 | 0 |
| Countryside Meadows | 3 mi | ★★★★★ | 15 | 0 |
| Washington Healthcare Center | 3.4 mi | ★★★★★ | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.