C76

WELLBROOKE OF CARMEL

Grade C 76/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
4/5
Health Insp.
3/5
Quality
5/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

74

Ownership

For profit - Limited Liability company

Total Fines

$15,646

Last Survey

N/A

12315 PENNSYLVANIA STREET, CARMEL, IN 46032
3175697200

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.61h
LPN
0.97h
CNA
1.94h
Total
3.52h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

WITHAM MEMORIAL HOSPITAL

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jul 2015

100%

TRILOGY HEALTHCARE HOLDINGS INC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2015

TRILOGY PROPERTY HOLDINGS LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Aug 2022

RHS PARTNERS OF CARMEL LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jul 2015

CARMACK, KYLIE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2023

HAFIDH, SAAD

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2025

BAYSTON, BRETT

IndividualCORPORATE DIRECTORSince Jan 2023

BRAND, JOHN

IndividualCORPORATE DIRECTORSince Jan 2015

CASTETTER, ANDREA

IndividualCORPORATE DIRECTORSince Jan 2023

HAWKINS, CLAUDE

IndividualCORPORATE DIRECTORSince Sep 2013

HORNBECKER, MICHAEL

IndividualCORPORATE DIRECTORSince Jan 2024

REAGAN, JULIE

IndividualCORPORATE DIRECTORSince Sep 2024

BARDOCZI, STEPHEN

IndividualCORPORATE OFFICERSince Sep 2013

BRAVERMAN, KELLY

IndividualCORPORATE OFFICERSince Dec 2021

SELLERS, DANIEL

IndividualCORPORATE OFFICERSince Jun 2024

Penalties & Fines (1)

$15,646total fines
DateTypeDescriptionAmount
Feb 23, 2024Fine$15,646

Health Inspection Deficiencies (36)

October 3, 2025Health1 deficiency
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Oct 4, 2025
September 12, 2025Health2 deficiencies
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Oct 3, 2025
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Aug 22, 2025
January 17, 2025Health5 deficiencies
0578DMinimal harm, Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Corrected Feb 7, 2025
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 7, 2025
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Feb 7, 2025
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Feb 7, 2025
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 7, 2025
August 1, 2024Health1 deficiency
0602DMinimal harm, Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 18, 2024
May 30, 2024Health1 deficiency
0839DMinimal harm, Isolated

Employ staff that are licensed, certified, or registered in accordance with state laws.

Administration Deficiencies

Corrected May 18, 2024
February 23, 2024Health2 deficiencies1 severe
0602DMinimal harm, Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Feb 15, 2024
0803JImmediate jeopardy, Isolated

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Corrected Jan 25, 2024
January 2, 2024Health2 deficiencies
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 26, 2023
0676DMinimal harm, Isolated

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Corrected Jan 19, 2024
November 20, 2023Health7 deficiencies
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 15, 2023
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 15, 2023
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Dec 15, 2023
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Dec 15, 2023
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Dec 15, 2023
0758DMinimal harm, Isolated

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 necessary and PRN use is limited.

Pharmacy Service Deficiencies

Corrected Dec 15, 2023
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Dec 15, 2023
October 25, 2022Health15 deficiencies1 severe
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Nov 18, 2022
0578EMinimal harm, Pattern

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Corrected Nov 18, 2022
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Nov 18, 2022
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Nov 18, 2022
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Nov 18, 2022
0690GActual harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Nov 18, 2022
0694DMinimal harm, Isolated

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Nov 18, 2022
0700DMinimal harm, Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Quality of Life and Care Deficiencies

Corrected Nov 18, 2022
0727FMinimal harm, Widespread

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Nursing and Physician Services Deficiencies

Corrected Nov 18, 2022
0758DMinimal harm, Isolated

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 necessary and PRN use is limited.

Pharmacy Service Deficiencies

Corrected Nov 18, 2022
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Nov 18, 2022
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Nov 18, 2022
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Nov 18, 2022
0909DMinimal harm, Isolated

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Environmental Deficiencies

Corrected Nov 18, 2022
0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Nov 18, 2022

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Frequently Asked Questions

What is the CareGrader rating for WELLBROOKE OF CARMEL?

WELLBROOKE OF CARMEL in CARMEL, Indiana has a CareGrader grade of C (Average), with a composite score of 76.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for WELLBROOKE OF CARMEL?

WELLBROOKE OF CARMEL has an overall CMS star rating of 4 out of 5, a health inspection rating of 3/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does WELLBROOKE OF CARMEL have?

WELLBROOKE OF CARMEL has 36 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has WELLBROOKE OF CARMEL been fined?

Yes. WELLBROOKE OF CARMEL has $15,646 in total fines from CMS enforcement actions across 1 penalty.

How many beds does WELLBROOKE OF CARMEL have?

WELLBROOKE OF CARMEL has 74 certified beds with approximately 53 current residents (72% occupancy). The facility is located at 12315 PENNSYLVANIA STREET, CARMEL, Indiana 46032. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.