Carmel, IN

Wellbrooke Of Carmel

3-star overall rating with 2-star inspections with $15,646 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

12315 Pennsylvania Street, Carmel, IN

(317) 569-7200

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 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

2015-06-03

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

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

0.66

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

1.05

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.10

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.81

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.71

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.37

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.55

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.61

CMS adjusted RN staffing hours

Adjusted total hours

3.52

CMS adjusted total nurse staffing hours

Case-mix index

1.48

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,169

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

Performance score

59.23

Composite VBP score used to determine payment impact.

Payment multiplier

1.0144

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.12

Baseline 22.12% · Performance 18.24% · Measure score 7.12 · Achievement 6.89 · Improvement 7.12

Healthcare-associated infections

8.98

Baseline 5.16% · Performance 5.15% · Measure score 8.98 · Achievement 8.98 · Improvement 0

Total nurse turnover

7.59

Baseline 64.29% · Performance 32.65% · Measure score 7.59 · Achievement 7.59 · Improvement 7.52

Adjusted total nurse staffing

Baseline 3.32 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.55%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 240 · Observed rate 10.42% · Lower 95% interval 9.06%
Discharge to community	66.22%	50.57% 15.6 pts better	Better than the National Rate · Eligible stays 217 · Observed rate 65.44% · Lower 95% interval 61.05%
Medicare spending per beneficiary	1.13	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 185 · Denominator 185
Falls with major injury	1.08%	0.77% 0.3 pts worse	Numerator 2 · Denominator 185
Discharge self-care score	80.92%	53.69% 27.2 pts better	Numerator 123 · Denominator 152
Discharge mobility score	73.68%	50.94% 22.7 pts better	Numerator 112 · Denominator 152
Pressure ulcers or injuries, new or worsened	2.7%	2.29% 0.4 pts worse	Numerator 5 · Denominator 185 · Adjusted rate 2.17%
Healthcare-associated infections requiring hospitalization	5.15%	7.12% 2 pts better	No Different than the National Rate · Eligible stays 160 · Observed rate 2.5% · Lower 95% interval 3.25%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 81
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 131
Discharge function score	76.97%	56.45% 20.5 pts better	Numerator 117 · Denominator 152
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 129 · Denominator 129
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	25.81%	25.2% 0.6 pts better	Numerator 24 · Denominator 93

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.0	1.6 0.6 pts better	1.9 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.2	1.5 1.3 pts better	1.8 1.6 pts better	Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.8%	93.6% 4.2 pts better	93.4% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 97.0% · Q3 97.2% · Q4 100.0% · 4Q avg 97.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.6%	95.4% 0.8 pts worse	95.5% 0.9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6%
Percentage of long-stay residents experiencing one or more falls with major injury	3.6%	3.8% 0.2 pts better	3.3% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.0% · Q3 0.0% · Q4 5.4% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	8.5%	24.6% 16.1 pts better	11.4% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.2% · Q3 2.9% · Q4 19.4% · 4Q avg 8.5%
Percentage of long-stay residents who lose too much weight	6.2%	5.6% 0.6 pts worse	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 12.5% · Q4 7.7% · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.8%	23.5% 5.7 pts better	19.6% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 16.0% · Q3 12.5% · Q4 18.5% · 4Q avg 17.8%
Percentage of long-stay residents who received an antipsychotic medication	5.8%	14.8% 9 pts better	16.7% 10.9 pts better	Long Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 4.5% · Q4 4.3% · 4Q avg 5.8% · 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	6.7%	13.3% 6.6 pts better	16.3% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.4%	11.7% 5.3 pts better	14.9% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 4.5% · Q3 0.0% · Q4 7.4% · 4Q avg 6.4% · 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 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 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	27.4%	24.2% 3.2 pts worse	19.8% 7.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 16.6% · Q3 16.0% · Q4 38.7% · 4Q avg 27.4%
Percentage of long-stay residents with pressure ulcers	8.1%	4.1% 4 pts worse	5.1% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 16.6% · Q3 5.8% · Q4 0.0% · 4Q avg 8.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	81.6% 17.9 pts better	81.7% 17.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 100.0% · Q3 99.4% · Q4 99.3% · 4Q avg 99.5%
Percentage of short-stay residents who had an outpatient emergency department visit	8.3%	10.5% 2.2 pts better	12.0% 3.7 pts better	Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 7.7% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.5%	1.3% 0.8 pts better	1.6% 1.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.8%	79.0% 19.8 pts better	79.7% 19.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.8%	22.4% 1.6 pts better	23.9% 3.1 pts better	Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 18.5% · Expected 21.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2026-01-21 · Fire 2026-01-21

7 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2025-01-17 · Fire 2025-01-17

7 health deficiencies

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

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-11-20 · Fire 2023-11-20

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2026-01-21

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Not marked corrected

F · Potential for more than minimal harm 2026-01-21

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Not marked corrected

E · Potential for more than minimal harm 2026-01-21

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Not marked corrected

E · Potential for more than minimal harm 2025-01-17

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-02-13

E · Potential for more than minimal harm 2025-01-17

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-02-13

E · Potential for more than minimal harm 2023-11-20

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-12-28

E · Potential for more than minimal harm 2023-11-20

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-12-28

E · Potential for more than minimal harm 2023-11-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-12-28

E · Potential for more than minimal harm 2023-11-20

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-12-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-21

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2026-01-23

D · Potential for more than minimal harm 2026-01-21

F644 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2026-01-23

D · Potential for more than minimal harm 2026-01-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-01-28

G · Actual harm 2025-12-02

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 2025-12-22

D · Potential for more than minimal harm 2025-10-03

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-10-04

D · Potential for more than minimal harm 2025-09-12

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-03

D · Potential for more than minimal harm 2025-09-12

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-01-17

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-01-17

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 2025-02-07

D · Potential for more than minimal harm 2025-01-17

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-01-17

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 2025-02-07

D · Potential for more than minimal harm 2025-01-17

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-02-07

D · Potential for more than minimal harm 2024-08-01

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-07-18

D · Potential for more than minimal harm 2024-05-30

F839 · Administration Deficiencies

Health

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

Corrected 2024-05-18

J · Immediate jeopardy 2024-02-23

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-01-25

D · Potential for more than minimal harm 2024-02-23

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-02-15

D · Potential for more than minimal harm 2024-01-02

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-12-26

D · Potential for more than minimal harm 2024-01-02

F676 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-01-19