Wellbrooke of Carmel

In the surveyor’s words

From the most serious findings on record at Wellbrooke of Carmel, in the surveyor’s own words.

• Immediate jeopardy, isolatedF803Feb 23, 2024

  Based on interview and record review, the facility failed to ensure staff followed the physician's order for a resident on a mechanical soft diet when the wrong texture of the diet was provided and failed to provide assistance with meals which resulted in a resident choking for 1 of 4 residents reviewed for dietary requirements. (Resident B) This deficient practice resulted in Resident B's death. The Immediate Jeopardy began on [DATE], when it was identified Resident B was provided a regular diet in place of a mechanical soft diet. Resident B choked on her dinner, was provided the Heimlich Maneuver, lost consciousness, and expired in the facility. […]

• Actual harm, isolatedF689Dec 2, 2025

  Based on observation, interview and record review, the facility failed to ensure a resident's comprehensive plan of care was followed and supervision was provided which resulted in unwitnessed falls for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining multiple injuries, including, but not limited to a fractured femur, hip, and multiple lacerations, some requiring sutures. Findings include:During a telephone interview, on 12/2/25 at 12:10 p.m., a family member indicated Resident B had five (5) falls in the last six months. Resident B had glass removed from her eye and face and sutures placed during the last fall. She was left alone in her room, and she was not supposed to be because of other falls. […]

• Actual harm, isolatedF690Oct 25, 2022

  Based on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for catheter care. (Resident 44) Resident 44 was not provided care to address concerns which developed after a urinary catheter was placed which led to a hospitalization with intravenous antibiotic intervention for the development of urosepsis. Finding includes: The record for Resident 44 was reviewed on 10/21/22 at 1:39 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care area assessment (CAA), dated 9/28/22, indicated the resident had triggered for an indwelling catheter related to [CONDITION(S)], hematuria, urinary retention and CKD. […]

• No harm, potential for more than minimal, widespreadF727Oct 25, 2022

  Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on site for 8 hours a day for 2 of 30 days, from September 18, 2022 to October 18, 2022. This deficient practice had the potential to effect 51 of 51 residents residing in the facility. (October 1, 2022 and October 15, 2022) Finding includes: During review of the schedule for licensed staff, on 10/21/2022 at 1:32 p.m., documentation of the hours worked lacked evidence of a RN for 8 consecutive hours, on October 1, 2022 and October 15, 2022. During an interview, at that time, the Scheduler reviewed the documents and verified there was no RN coverage, for 8 consecutive hours on those dates. A current facility policy, regarding RN coverage in the facility, was requested on 10/21/2022 at 3:21 p.m. […]

• No harm, potential for more than minimal, patternF578Oct 25, 2022

  Based on interview and record review, the facility failed to ensure an advance directive was reviewed, obtained or updated to reflect admitted residents' current wishes for 6 of 55 residents who were reviewed for advance directives. (Resident 26, 42, 46, 100, 200 and 201). Findings include: 1. On [DATE] at 2:08 p.m., during a random observation, Resident 26 was confused to date, time, and place. She was not able to be interviewed. The record for Resident 26 was reviewed on [DATE] at 8:52 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 26's record indicated on her banner at the top of her EMR (electronic medical record) screen and face sheet, she wanted all resuscitation procedures if her heart stopped beating and/or she stopped breathing (full code status). […]