01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-17 | 2 | 2026-03-17 | 0 |
| Cycle 2 | 2025-04-28 | 6 | 2025-04-28 | 1 |
| Cycle 3 | 2024-04-04 | 11 | 2024-04-04 | 9 |
CMS CCN 1558082026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Wellbrooke Of Westfield
937 E 186Th Street · Westfield, IN 46074 · Hamilton County
Certified beds70CMS provider file
Recent citation rows29current CMS citation release
Penalty rows0current 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
29 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-17 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2026-03-302026-03-17 · 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: Past Non-Compliance · 2026-03-062025-06-05 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Past Non-Compliance · 2025-05-08 · complaint2025-04-28 · 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 · 2025-05-162025-04-28 · 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 · 2025-05-162025-04-28 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-05-162025-04-28 · 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 · 2025-05-162025-04-28 · 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 · 2025-05-162025-04-28 · FIREK0921Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2025-08-122024-04-04 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2024-05-092024-04-04 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Deficient, Provider has date of correction · 2024-05-012024-04-04 · HEALTHF0623Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Correction field: Deficient, Provider has date of correction · 2024-05-012024-04-04 · 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 · 2024-05-012024-04-04 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-05-012024-04-04 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2024-05-012024-04-04 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2024-05-01 · complaint2024-04-04 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-05-012024-04-04 · 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: Deficient, Provider has date of correction · 2024-05-012024-04-04 · 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 · 2024-05-012024-04-04 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-05-092024-04-04 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-05-092024-04-04 · FIREK0344Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have an alternate power supply for its alarm system.
Correction field: Deficient, Provider has date of correction · 2024-05-092024-04-04 · 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 · 2024-05-092024-04-04 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-05-0903 / 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 |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- HANCOCK REGIONAL HOSPITALOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2015
- BOND, MARIAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2021
- CLARK, TIMOTHYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2025
- DAUGHERTY, JOSHUAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2020
- FELKER, DEANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2015
- JOYNER, SARAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2022
- LONG, STEVENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/14/2018
- WILLARD, LACEYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2022
- WILSON, ROYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2015
- LCS WESTFIELD LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2015
- HASHMI, SYEDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/15/2025
- LONG, STEVENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/13/2022
- MILLER, MAGGIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/08/2023
- BOND, MARIAIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 07/01/2021
- CLARK, TIMOTHYIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 05/01/2025
- DAUGHERTY, JOSHUAIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 01/01/2020
- FELKER, DEANIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 05/01/2025
- JOYNER, SARAIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 01/01/2022
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 hours4.28per resident day
RN hours0.81per resident day
Weekend nurse hours3.84per resident day
Staff turnover46.0%CMS reported field
06 / LOCAL RECORDS
Open the Westfield ledger →