Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Carmel during CMS and state inspections, most recent first.
A resident with type 2 DM, vitamin D deficiency, and dehydration had a documented 8.39% wt loss in under 30 days, but the physician and family were not notified in a timely manner. The care plan directed staff to monitor wt and notify the MD and family of wt loss, yet documentation showed delayed notification to the MD and even later notification to the resident’s representative. Clinical support staff stated the facility should have notified both parties of the wt loss.
A resident with major depressive disorder, generalized anxiety disorder, and depression had an inaccurate PASARR Level I screen that did not include those mental health diagnoses and stated that a Level II was not required. The SSD stated the diagnoses should have been included on the PASARR, and the facility policy required PASRR evaluation for serious mental illness and Level I screening for change in status.
TB skin tests were read too early for two residents. One resident with spinal stenosis, CHF, HTN, and DM2 had two TSTs read in less than 48 hours after administration, and another resident with COPD, dementia, HTN, and osteomyelitis had a TST read before the 48- to 72-hour window. The DON stated TB skin tests were supposed to be read within 48 to 72 hours, and the IP noted the MAR timing needed adjustment to ensure proper spacing.
A resident with dementia and a history of repeated falls sustained multiple injuries, including fractures and lacerations, after being left unattended in her room and bathroom despite care plan interventions requiring supervision. Staff failed to consistently follow and communicate the resident's fall prevention measures, leading to several unwitnessed falls and significant harm.
A resident with Parkinson's disease did not receive the correct dose of Rytary after an admitting nurse entered an incorrect order and the pharmacy, referencing an outdated profile, confirmed the lower dose. The error persisted until a nurse questioned the dosage, revealing that both nursing and pharmacy staff failed to verify the most current physician order, resulting in the resident receiving less medication than prescribed.
The facility did not ensure that pain assessments were completed and documented before and after administering narcotic pain medication to two residents, despite physician orders and EMAR requirements. An LPN administered Oxycodone on multiple occasions without the required assessments, and interviews confirmed that the residents had not recently requested such medication, with one preferring Tylenol.
Two residents with complex medical conditions received Oxycodone as indicated by narcotic count sheets, but the administration was not documented on the EMAR. Interviews revealed that neither resident had requested the medication on the dates in question, and staff failed to follow proper documentation procedures.
A facility failed to update a resident's code status to DNR in their electronic medical record after receiving a signed declaration and order. Despite the form being scanned into the system, the resident's status remained listed as full code. Interviews revealed that staff relied on incorrect information in emergencies, and the facility's policy on advanced directives was not followed.
The facility failed to conduct required care plan meetings for three residents, leading to a deficiency in care planning. A resident with depression and Alzheimer's disease missed a quarterly meeting, while another with Alzheimer's and hallucinations had not had a meeting since May. A third resident with cancer and malnutrition reported not being invited to a meeting since July. The Clinical Support Nurse cited employee turnover and focus on rehab residents as reasons for the oversight.
The facility failed to follow physician's orders for medication administration for three residents, leading to deficiencies in care. A resident received midodrine despite high blood pressure, another received carvedilol with a low heart rate, and a third had elevated blood sugar without physician notification. The facility lacked a policy for blood glucose monitoring.
The facility failed to accurately record urine output for two residents with suprapubic catheters, using vague terms like 'large', 'medium', and 'small' instead of precise measurements in milliliters. Staff interviews revealed that CNAs were responsible for charting output but often used imprecise terms, and the facility lacked a policy on documenting intake and outputs, leading to inconsistent recording practices.
A facility failed to document medication administration for a resident in the MAR, missing entries for several medications including buspirone, cholecalciferol, Cymbalta, docusate sodium, and gabapentin. The Corporate Support Nurse confirmed that medications should be documented post-administration, as per facility policy.
A resident's credit card was misappropriated by a staff member during her stay at the facility. The resident, with a history of chronic kidney disease and diabetes, reported the card missing after returning from activities and therapy. An investigation revealed that a housekeeper, who was under training, used the card at a McDonald's during her lunch break. The housekeeper left the facility and did not return, leading to her termination.
The facility failed to ensure that a staff member had the appropriate qualifications and current certification to perform the duties of a CNA and QMA. Employee 1 worked under another person's name and provided certifications that did not match his employment records. Additionally, his job-specific orientation checklists were incomplete and unsigned by the trainer. The deficiency was identified following an anonymous complaint and a news report.
Failure to Notify Physician and Family of Significant Weight Loss
Penalty
Summary
The facility failed to ensure that Resident 23’s physician and resident representative were notified when the resident’s weight was obtained and documented and showed a significant loss. Resident 23’s clinical record showed diagnoses including type 2 diabetes, vitamin D deficiency, and dehydration. The care plan, dated 11/29/23, directed staff to monitor and record weight and to notify the physician and family of weight loss. The electronic record showed weights of 155 pounds on 3/8/25, 157.4 pounds on 4/10/25, and 144.2 pounds on 5/6/25, reflecting an 8.39% weight loss in under 30 days. A facility report dated 5/14/25 indicated Resident 23 had a 5% weight change in 30 days. There was no documentation that the physician was notified until eight days after the weight loss was documented, and no documentation that the family was notified until 5/28/25, which was 22 days after the weight loss was documented. During interview, Clinical Support 1 stated the facility should have notified the physician and family of the weight loss. The facility policy titled Physician-Provider Notification Guidelines stated that the physician or practitioner should be made aware of diagnostic testing results or changes in condition in a timely manner, and that attempts to notify the physician/provider and their response should be documented in the resident electronic health record.
Inaccurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was accurate for Resident 14, who had diagnoses of major depressive disorder, generalized anxiety disorder, and depression. The resident’s PASARR Level I screen, dated 4/27/25, indicated that a PASARR Level II was not required and stated the resident did not have a suspected mental illness, intellectual disability, or related condition, but the screen did not include the resident’s major depressive disorder, generalized anxiety disorder, or depression. During interview, the Social Services Director stated that major depressive disorder should have been on the PASARR and that if the facility noted a discrepancy with a PASARR, a new PASARR should be submitted. The facility policy titled Indiana PASRR stated that all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness and that PASRR Level I is completed for change in status.
TB Skin Tests Read Too Early
Penalty
Summary
The facility failed to ensure tuberculosis tests were administered according to acceptable standards of practice for 2 of 5 residents reviewed for infection control. For Resident 1, whose diagnoses included cervical region spinal stenosis, lumbar region fusion of the spine, chronic diastolic congestive heart failure, essential primary hypertension, and type 2 diabetes mellitus without complications, TB skin test documentation showed a test was administered in the left forearm at 10:05 p.m. on 12/24/25 and read as negative at 4:46 p.m. on 12/26/25, which was less than 48 hours after administration. A second TB skin test for the same resident was administered in the left forearm at 9:25 p.m. on 1/7/26 and read as negative at 3:15 p.m. on 1/9/26, also less than 48 hours after administration. For Resident 62, whose diagnoses included COPD, dementia, hypertension, and osteomyelitis, TB skin test documentation showed a test was administered in the left forearm at 10:00 p.m. on 1/9/26 and read as negative at 5:09 p.m. on 1/11/26, which was less than 48 hours after administration. During interview, the DON stated TB skin tests were supposed to be read within 48 to 72 hours, and the IP stated the facility needed to change the timing of the TB orders on the MAR to ensure proper spacing between administering and reading the tests. The facility policy indicated a baseline two-step TST shall be completed upon admission, and the CDC document stated the skin test should be read between 48 and 72 hours after administration.
Failure to Follow Care Plan and Provide Supervision Resulting in Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was followed and that adequate supervision was provided, resulting in multiple unwitnessed falls for a resident with significant cognitive impairment and a history of repeated falls. The resident, who had diagnoses including dementia, periprosthetic fracture, repeated falls, and major depressive disorder, experienced five falls within six months, each resulting in injury. These injuries included skin tears, bruises, lacerations, a fractured left hip, and a periprosthetic fracture around an internal prosthetic left hip joint. Despite documented care plan interventions specifying that the resident was not to be left unattended in her room or bathroom, staff failed to consistently implement these measures. Multiple incidents were documented where the resident was left alone, contrary to her care plan. In one instance, the resident was left alone in her bathroom and fell while attempting to self-transfer, resulting in a femur fracture. On another occasion, she was left alone in her room and fell, sustaining a head laceration that required sutures. In another event, a CNA left the resident in the bathroom to retrieve supplies, during which time the resident moved herself into her room and fell, resulting in facial lacerations and additional sutures. Staff interviews and documentation revealed that some staff were unaware of the resident's fall interventions, and there was a lack of consistent communication regarding care plan updates and interventions during shift reports. Observations confirmed the resident had visible injuries, including bruising and sutures on her face and forehead. Family members expressed concern about the resident being left alone despite assurances from management that this would not occur. Facility records and interviews indicated that care plan interventions were not reliably communicated or followed, contributing to the resident's repeated, injurious falls. The facility's policies required care plan updates and communication of interventions, but these were not effectively implemented for this resident.
Incorrect Medication Dosage Administered Due to Order Entry and Pharmacy Review Errors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's disease, history of stroke, and weakness was not provided with the correct dosage of Rytary, a medication used to treat Parkinson's symptoms. The resident's physician orders for Rytary changed multiple times, with one order indicating four capsules four times daily, but due to an error by the admitting nurse, the order was incorrectly entered as one capsule four times daily. This incorrect dosage was then perpetuated when the pharmacy, upon review, referenced an older resident profile and confirmed the lower dose, leading to the resident receiving less medication than prescribed. The issue was identified after a weekend nurse questioned the medication dosage, prompting further review. Interviews with the DON and review of facility communications revealed that both nursing and pharmacy staff contributed to the error by relying on outdated information and not verifying the most current physician order. The facility's policy required an Immediate Medication Regimen Review (IMRR) by a licensed pharmacist upon request, but the review did not catch the discrepancy, resulting in the resident not receiving the intended medication dose for a period of time.
Failure to Document Pain Assessments Before and After Narcotic Administration
Penalty
Summary
The facility failed to ensure that pain assessments were completed both prior to and after the administration of narcotic pain medication for two residents. For one resident with diagnoses including dementia, chronic kidney disease, malignant melanoma, anxiety disorder, and chronic lumbar degeneration, there were multiple instances where Oxycodone was administered without documentation of a pain assessment before or after the medication was given, as required by the physician's order and the EMAR. Specific dates and times were identified where this documentation was missing. Another resident, with diagnoses such as dysarthria following cerebral infarction, right shoulder stiffness, type II diabetes with neuropathy, and major depressive disorder, also received Oxycodone without the required pain assessments being documented before and after administration. Interviews with both residents and a family member indicated that the residents had not requested strong pain medication recently, and one preferred Tylenol for pain. The Executive Director confirmed that the LPN should have completed pain assessments as required.
Failure to Document Administration of Narcotic Pain Medications
Penalty
Summary
The facility failed to ensure that narcotic pain medications administered to two residents were properly documented on the electronic medication administration record (EMAR). For both residents, the narcotic count sheets indicated that Oxycodone had been given on multiple occasions, but there were no corresponding signatures or documentation on the EMAR to confirm administration. Interviews with the residents revealed that they had not requested the as-needed narcotics on the dates in question, and one resident's family member confirmed a preference for non-narcotic pain relief. The lack of documentation was also confirmed during interviews with facility staff. The residents involved had significant medical histories, including dementia, chronic kidney disease, malignant melanoma, anxiety disorder, chronic lumbar degeneration, dysarthria following cerebral infarction, shoulder stiffness, type II diabetes with neuropathy, and major depressive disorder. Despite physician orders for as-needed Oxycodone, the absence of EMAR documentation for the administered doses constituted a failure to follow the facility's policy on the right documentation of medication administration.
Failure to Update Resident's Code Status in Medical Record
Penalty
Summary
The facility failed to update a resident's code status in their electronic medical record after receiving an out of hospital do not resuscitate (DNR) declaration and order. The resident, who had multiple diagnoses including Alzheimer's disease, hypertension, and chronic kidney disease, signed the DNR form, which was subsequently signed by the physician six days later. Despite the form being scanned into the electronic medical record, the resident's code status remained listed as full code in various parts of the medical record, including the top banner information and face sheet. Interviews with facility staff revealed that the Director of Nursing acknowledged the oversight in updating the charting system with the correct order. An LPN indicated that in an emergency, staff would rely on the computer's top banner information to determine whether to initiate CPR or honor a DNR request. The facility's policy on advanced directives emphasized the importance of obtaining and following residents' end-of-life care wishes, including confirming code status and obtaining a physician's order as part of the medical record. However, this policy was not adhered to in the case of the resident in question.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were offered or held for three residents, leading to a deficiency in care planning. Resident 23, diagnosed with depression, anxiety disorder, and Alzheimer's disease, did not have a documented quarterly care plan meeting between April and December 2024. The Clinical Support Nurse confirmed that only two meetings were held during this period, missing the required quarterly meeting. Resident 29, with Alzheimer's disease, dementia, insomnia, and visual hallucinations, had not had a care plan meeting since May 2024. Despite experiencing increased hallucinations and being prescribed Risperidone, the facility missed the quarterly care plan meeting for this resident. The Clinical Support Nurse acknowledged the oversight during an interview. Resident 30, diagnosed with malignant neoplasm, severe protein-calorie malnutrition, and muscle weakness, reported not being invited to a care plan meeting for a long time. The facility had not conducted a care plan meeting for this resident since July 2024, and the Clinical Support Nurse admitted that the last quarterly meeting was missed due to significant employee turnover and a focus on rehab residents. The facility's policy requires quarterly meetings and communication with residents and their representatives, but these were not adhered to, resulting in a failure to meet care planning requirements.
Medication Administration Errors and Lack of Physician Notification
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication administration for three residents, leading to deficiencies in quality of care. Resident 194, diagnosed with conditions including metabolic encephalopathy and type 2 diabetes, was prescribed midodrine with instructions to hold the medication if systolic blood pressure exceeded 120. Despite this, the medication was administered on multiple occasions when the resident's systolic blood pressure was above the specified threshold, without notifying the physician. Resident 4, with diagnoses including hypertension and type 2 diabetes, was prescribed carvedilol with instructions to hold the medication if the heart rate was below 65 beats per minute. The medication was administered several times when the resident's heart rate was below this parameter, contrary to the physician's order. The care plan indicated a potential for cardiovascular distress, yet the medication was not held as required. Resident 2, who had diabetes mellitus and other conditions, had a physician's order for insulin administration based on blood sugar levels, with instructions to notify the physician if blood sugar exceeded 400. On one occasion, the resident's blood sugar was recorded at 576, but there was no documentation of physician notification. The facility lacked a policy for blood glucose monitoring, and the Director of Nursing confirmed the physician was not notified as required.
Inaccurate Documentation of Urine Output for Residents with Catheters
Penalty
Summary
The facility failed to accurately record the urine output for two residents with suprapubic catheters. Resident 20's clinical record indicated a care plan to monitor urinary output and assist with catheter care, with a physician's order to monitor catheter output every shift. However, the Treatment Administration Record (TAR) showed that urine output was documented using vague terms like 'large', 'medium', and 'small' instead of precise measurements in milliliters. Interviews with staff revealed that CNAs were responsible for charting urine output, but often used these imprecise terms, which were not in line with the facility's expectations for accurate documentation. Similarly, Resident 1, who had a suprapubic catheter due to urethral stricture, had a physician's order to monitor urinary output three times a day. The TAR for this resident also showed urine output recorded in non-specific terms rather than in milliliters. Interviews with CNAs and LPNs confirmed that the output should have been documented in milliliters, but the facility lacked a policy on documenting intake and outputs, contributing to the inconsistency in recording practices. The Indiana State Department of Health Nurse Aide Curriculum emphasizes the importance of accurately measuring and recording urine output, as decisions regarding resident care may be based on these reports. The facility's failure to adhere to these guidelines and accurately document urine output in milliliters for residents with catheters represents a deficiency in providing appropriate care and monitoring for these residents.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident, identified as Resident 30, in the Medication Administration Record (MAR). The clinical record review revealed that on a specific day, there was no documentation indicating whether several medications were administered or not. These medications included buspirone for adjustment disorder, cholecalciferol as a supplement, Cymbalta for adjustment disorder, docusate sodium for constipation, and gabapentin for neuropathy. Additionally, there were seven other instances of missed documentation in the December MAR. During an interview, the Corporate Support Nurse confirmed that medications should be documented after administration. The facility's policy, revised in January 2017, states that if a dose of regularly scheduled medication is withheld, refused, not available, or given at a different time, it must be documented in the MAR or electronic health record. This lack of documentation indicates a failure to adhere to the facility's medication administration policy.
Resident's Credit Card Misappropriated by Staff
Penalty
Summary
The facility failed to ensure the safety and security of a resident's credit card during her admission, leading to its misappropriation. Resident B, who had a medical history including chronic kidney disease, hypertension, and diabetes, reported her credit card missing with unauthorized charges. The card was last seen in her phone case wallet before she left her room for activities and therapy. Upon returning, she discovered the card missing and found it had been used at a McDonald's. The incident occurred between the time she left her room and returned after lunch. An investigation revealed that Housekeeper 1, who was under training, was involved in the theft. Housekeeper 1 was observed eating McDonald's food during her lunch break, which coincided with the time the unauthorized transaction occurred. The housekeeper left the facility during her break and did not return, leading to her termination. The facility's investigation included reviewing employee records and interviewing staff, confirming the involvement of Housekeeper 1 in the theft of Resident B's credit card.
Failure to Verify Staff Credentials and Ensure Proper Orientation
Penalty
Summary
The facility failed to ensure that a staff member, Employee 1, had the appropriate qualifications and current certification to perform the duties of a Certified Nursing Assistant (CNA) and a Qualified Medication Aide (QMA). Employee 1 worked at the facility for a total of 34 days, during which he was suspended for a week due to a staff-to-staff incident and did not work for another week due to COVID-19. It was discovered that Employee 1 had worked under the name of another person and provided CNA and QMA certifications under a different name than his employment records. The facility did not verify the discrepancy in names, which Employee 1 attributed to a recent marriage, although no marriage license was found in his employee file. Additionally, Employee 1's job-specific orientation checklists for his CNA and QMA roles were incomplete and unsigned by the trainer, indicating a lack of proper orientation before he began working alone on the floor as a CNA and QMA. The facility's failure to ensure proper certification and orientation for Employee 1 led to his termination for poor job performance and unsatisfactory interactions with staff. The deficiency was identified following an anonymous complaint and a subsequent news report that revealed Employee 1 had worked under another person's LPN license. The facility's investigation confirmed that Employee 1 had used different names and provided certifications that did not match his employment records. The facility's oversight in verifying Employee 1's credentials and ensuring proper orientation contributed to the deficiency. The deficient practice was corrected on 5/18/24, prior to the start of the survey, and was therefore past noncompliance.
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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 Carmel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Carmel | 0.7 mi | ★★★★★ | 0 | 0 |
| Barrington Of Carmel, The | 0.8 mi | ★★★★★ | 0 | 0 |
| Carmel Health & Living Community | 1.6 mi | ★★★★★ | 17 | 0 |
| Restoracy Of Carmel | 1.7 mi | ★★★★★ | 8 | 0 |
| Retreat At The Stratford, The | 2.6 mi | ★★★★★ | 6 | 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.