Indianapolis, IN

Wellbrooke Of Avon

4-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

10307 E County Rd 100 N,, Indianapolis, IN

(317) 273-2144

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 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

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Trilogy Health Services

Operator or chain grouping

Approved since

2013-10-23

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

Within the last 12 months

Family council

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.30

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.51

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.26

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

4.07

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.80

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.64

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

1.07

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.14

CMS adjusted RN staffing hours

Adjusted total hours

3.57

CMS adjusted total nurse staffing hours

Case-mix index

1.56

Higher values indicate more complex resident acuity

RN turnover

27%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

29%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,906

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

47.02

Composite VBP score used to determine payment impact.

Payment multiplier

1.0005

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.88

Baseline 22.77% · Performance 19.11% · Measure score 5.88 · Achievement 5.01 · Improvement 5.88

Healthcare-associated infections

2.14

Baseline 7.97% · Performance 7.20% · Measure score 2.14 · Achievement 2.14 · Improvement 2.11

Total nurse turnover

9.46

Baseline 38.46% · Performance 25.00% · Measure score 9.46 · Achievement 9.46 · Improvement 9

Adjusted total nurse staffing

1.33

Baseline 3.75 hours · Performance 3.46 hours · Measure score 1.33 · Achievement 1.33 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.81%	10.72% 2.1 pts worse	No Different than the National Rate · Eligible stays 307 · Observed rate 13.68% · Lower 95% interval 9.32%
Discharge to community	68.67%	50.57% 18.1 pts better	Better than the National Rate · Eligible stays 302 · Observed rate 63.25% · Lower 95% interval 63.12%
Medicare spending per beneficiary	0.92	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 207 · Denominator 207
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 207
Discharge self-care score	69.86%	53.69% 16.2 pts better	Numerator 102 · Denominator 146
Discharge mobility score	53.42%	50.94% 2.5 pts better	Numerator 78 · Denominator 146
Pressure ulcers or injuries, new or worsened	0.48%	2.29% 1.8 pts better	Numerator 1 · Denominator 207 · Adjusted rate 0.44%
Healthcare-associated infections requiring hospitalization	7.19%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 181 · Observed rate 7.18% · Lower 95% interval 4.43%
Staff COVID-19 vaccination coverage	1.25%	8.2% 6.9 pts worse	Numerator 1 · Denominator 80
Staff flu vaccination coverage	27.78%	42% 14.2 pts worse	Numerator 35 · Denominator 126
Discharge function score	75.34%	56.45% 18.9 pts better	Numerator 110 · Denominator 146
Transfer of health information to provider	97.18%	95.95% 1.2 pts better	Numerator 138 · Denominator 142
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 45 · Denominator 45
Resident COVID-19 vaccinations up to date	53%	25.2% 27.8 pts better	Numerator 53 · Denominator 100

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
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	0.0%	3.8% 3.8 pts better	3.3% 3.3 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 who have depressive symptoms	11.2%	24.6% 13.4 pts better	11.4% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 4.8% · Q4 14.3% · 4Q avg 11.2%
Percentage of long-stay residents who lose too much weight	3.1%	5.6% 2.5 pts better	5.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.4%	23.5% 13.1 pts better	19.6% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4%
Percentage of long-stay residents who received an antipsychotic medication	9.1%	14.8% 5.7 pts better	16.7% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · 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 ability to walk independently worsened	20.5%	13.3% 7.2 pts worse	16.3% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 20.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.2%	11.7% 2.5 pts better	14.9% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 9.2% · 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 · 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	26.1%	24.2% 1.9 pts worse	19.8% 6.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 25.8% · Q4 27.8% · 4Q avg 26.1%
Percentage of long-stay residents with pressure ulcers	0.0%	4.1% 4.1 pts better	5.1% 5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine	96.9%	81.6% 15.3 pts better	81.7% 15.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 97.7% · Q3 96.1% · Q4 96.9% · 4Q avg 96.9%
Percentage of short-stay residents who had an outpatient emergency department visit	5.5%	10.5% 5 pts better	12.0% 6.5 pts better	Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 5.6% · Expected 11.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.2%	79.0% 14.2 pts better	79.7% 13.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.3%	22.4% 0.1 pts better	23.9% 1.6 pts better	Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 22.5% · Expected 24.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-07 · Fire 2025-03-07

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-02-02 · Fire 2024-02-02

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2022-10-25 · Fire 2022-10-25

14 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-03-07

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-04-03

E · Potential for more than minimal harm 2024-02-02

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-04-23

E · Potential for more than minimal harm 2022-10-25

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-02-02

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-03-07

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-03-07

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-03-07

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-03-07

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 2025-03-31

D · Potential for more than minimal harm 2025-03-07

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 2025-03-31

D · Potential for more than minimal harm 2024-05-24

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 2024-06-14

D · Potential for more than minimal harm 2024-05-24

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 2024-06-14

E · Potential for more than minimal harm 2024-02-02

F657 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-03-01

D · Potential for more than minimal harm 2024-02-02

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 2024-03-01

D · Potential for more than minimal harm 2024-02-02

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-03-01

D · Potential for more than minimal harm 2024-02-02

F690 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-03-01

D · Potential for more than minimal harm 2024-02-02

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-03-01

D · Potential for more than minimal harm 2024-02-02

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 2024-03-01

G · Actual harm 2022-10-25

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-11-23

G · Actual harm 2022-10-25

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 2022-11-23

G · Actual harm 2022-10-25

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2022-11-23

E · Potential for more than minimal harm 2022-10-25

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-11-23

E · Potential for more than minimal harm 2022-10-25

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 2022-11-23