01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-21 | 7 | 2026-01-21 | 3 |
| Cycle 2 | 2025-01-17 | 6 | 2025-01-17 | 2 |
| Cycle 3 | 2023-11-20 | 12 | 2023-11-20 | 4 |
CMS CCN 1558332026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Wellbrooke Of Carmel
12315 Pennsylvania Street · Carmel, IN 46032 · Hamilton County
Certified beds74CMS provider file
Recent citation rows34current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
34 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-21 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2026-01-232026-01-21 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2026-01-232026-01-21 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-01-282026-01-21 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2026-03-042026-01-21 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-03-042026-01-21 · FIREK0781Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Correction field: Deficient, Provider has date of correction · 2026-03-042025-12-02 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-12-22 · complaint2025-10-03 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-10-04 · complaint2025-09-12 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-10-03 · complaint2025-09-12 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Past Non-Compliance · 2025-08-22 · complaint2025-01-17 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-02-072025-01-17 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-02-072025-01-17 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-02-072025-01-17 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-02-072025-01-17 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-02-072025-01-17 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2025-02-132025-01-17 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-02-132024-08-01 · HEALTHF0602Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Past Non-Compliance · 2024-07-18 · complaint2024-05-30 · HEALTHF0839Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Correction field: Past Non-Compliance · 2024-05-18 · complaint2024-02-23 · HEALTHF0602Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Past Non-Compliance · 2024-02-15 · complaint2024-02-23 · HEALTHF0803Severity J · isolated immediate jeopardy
Nutrition and Dietary Deficiencies
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.
Correction field: Past Non-Compliance · 2024-01-25 · complaint2024-01-02 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Past Non-Compliance · 2023-12-26 · complaint2024-01-02 · HEALTHF0676Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Correction field: Deficient, Provider has date of correction · 2024-01-19 · complaint2023-11-20 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2023-12-1503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-02-23 | Fine | $15,646 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- WITHAM MEMORIAL HOSPITALOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2015
- BAYSTON, BRETTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- BRAND, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- CASTETTER, ANDREAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- HAWKINS, CLAUDEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/09/2013
- HORNBECKER, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- REAGAN, JULIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/25/2024
- BARDOCZI, STEPHENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/03/2013
- BRAVERMAN, KELLYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/01/2021
- SELLERS, DANIELIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/20/2024
- RHS PARTNERS OF CARMEL LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2015
- CARMACK, KYLIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/06/2023
- HAFIDH, SAADIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/15/2025
- BARNEY, LEIGHIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/09/2025
- DAVIS, DAVIDIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 08/29/2025
- AMERICAN HEALTHCARE REIT HOLDINGS LPOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/01/2015
- AMERICAN HEALTHCARE REIT INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/01/2018
- CONTINENTAL MERGER SUB LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/01/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.55per resident day
RN hours0.90per resident day
Weekend nurse hours3.14per resident day
Staff turnover49.2%CMS reported field
06 / LOCAL RECORDS
Open the Carmel ledger →Other published facilities nearby
Barrington Of Carmel, The8 beds · CMS overall 5/55 citation rowsBridgewater Healthcare Center120 beds · CMS overall 5/530 citation rowsCarmel Health & Living Community188 beds · CMS overall 2/547 citation rowsMajestic Care Of Carmel94 beds · CMS overall 2/538 citation rowsMcgivney Health Care Center37 beds · CMS overall 2/560 citation rowsRestoracy Of Carmel72 beds · CMS overall 4/541 citation rowsRetreat At The Stratford, The18 beds · CMS overall 4/539 citation rows