Wellbrooke of Carmel
12315 Pennsylvania Street, Carmel, IN 46032 · Hamilton County · 74 certified beds · avg 53 residents/day · certified since Jun 3, 2015
Part of chain: TRILOGY HEALTH SERVICES (123 facilities, chain avg rating 4.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Feb 23, 2024 · F-0803 · triggered by a complaint
The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Why it matters: When menus aren't planned and followed properly, residents may not get the nutrition their health depends on.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 25, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Dec 2, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 22, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 2, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 3, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Sep 12, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 12, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| May 30, 2024 | D · Potential for harm, one-off | The facility employed staff who were not licensed, certified, or registered as required by state law. · from a complaint |
| Feb 23, 2024 | ▲ J · Immediate jeopardy, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Feb 23, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jan 2, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 2, 2024 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Nov 20, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Nov 20, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Nov 20, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 20, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 20, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Nov 20, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Nov 20, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (5 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 0 | D |
| 2024 | 6 | 1 | J ▲ |
| 2025 | 9 | 1 | G ▲ |
| 2026 | 3 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $15,646.
| Date | Type | Amount / length |
|---|---|---|
| Feb 23, 2024 | Fine | $15,646 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Indiana avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.18 | 3.42 | 3.95 | bottom 41% in Indiana; bottom 21% in the U.S. |
| Registered Nurse hours | 0.81 | 0.62 | 0.69 | top 18% in Indiana; top 27% in the U.S. |
| Weekend total nurse staffing | 2.81 | 3.01 | 3.50 | bottom 46% in Indiana; bottom 22% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.77 | 0.47 | 0.48 | top 11% in Indiana; top 13% in the U.S. |
| Total nursing staff turnover (%) | 49.2 | 45.9 | 45.8 | bottom 39% in Indiana; bottom 39% in the U.S. |
| RN turnover (%) | 66.7 | 40.4 | 42.9 | bottom 12% in Indiana; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.55, RN 0.90, weekend 3.14. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Witham Memorial Hospital | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/01/2015 |
| American Healthcare Reit Holdings LP | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| American Healthcare Reit INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Bardoczi, Stephen | Individual | Corporate Officer | NOT APPLICABLE | 09/03/2013 |
| Barney, Leigh | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/09/2025 |
| Bayston, Brett | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Brand, John | Individual | Corporate Director | NOT APPLICABLE | 01/01/2015 |
| Braverman, Kelly | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2021 |
| Carmack, Kylie | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/06/2023 |
| Carmack, Kylie | Individual | ADP of the SNF | NOT APPLICABLE | 07/09/2025 |
| Castetter, Andrea | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Continental Merger Sub LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2021 |
| Davis, David | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 08/29/2025 |
| Gahc3 Trilogy JV LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Gahc4 Trilogy JV LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Hafidh, Saad | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/15/2025 |
| Hafidh, Saad | Individual | ADP of the SNF | NOT APPLICABLE | 07/15/2025 |
| Hawkins, Claude | Individual | Corporate Director | NOT APPLICABLE | 09/09/2013 |
| Hornbecker, Michael | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Paragon Outpatient Rehabilitation Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Majestic Care of Carmel | 0.7 mi | Carmel, IN | ★★☆☆☆ | 3/5 | |
| Barrington of Carmel, the | 0.8 mi | Carmel, IN | ★★★★★ | 5/5 | |
| Carmel Health & Living Community | 1.6 mi | Carmel, IN | ★★☆☆☆ | 2/5 | |
| Restoracy of Carmel | 1.7 mi | Carmel, IN | ★★★★☆ | 3/5 | |
| Retreat at the Stratford, the | 2.6 mi | Carmel, IN | ★★★★☆ | 4/5 | |
| Copper Trace Health & Living Community | 3.4 mi | Westfield, IN | ★★★☆☆ | 3/5 | |
| Bridgewater Healthcare Center | 3.5 mi | Carmel, IN | ★★★★★ | 4/5 | |
| McGivney Health Care Center | 4.0 mi | Carmel, IN | ★★☆☆☆ | 3/5 | |
| Brickyard Healthcare - Willow Springs Care Center | 4.3 mi | Indianapolis, IN | ★★☆☆☆ | 2/5 | |
| Spring Mill Meadows | 4.4 mi | Indianapolis, IN | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 155833.