Wellbrooke of Carmel
12315 Pennsylvania Street, Carmel, IN 46032
Wellbrooke of Carmel is a nursing home in Carmel, Indiana. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 3 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (317) 569-7200
- Last standard health inspection
- January 21, 2026 (9 months ago)
- Certified beds
- 74
- Residents per day, on average
- 50.8
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Witham Memorial Hospital
- Chain
- Trilogy Health Services
- Takes part in
- Medicare and Medicaid
More health citations than the Indiana average (25 vs 23).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
3 citations
Health inspection on January 21, 2026
CMS lists this as a standard inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on January 23, 2026.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on January 23, 2026.
CMS has cited this home for F0644 2 times since 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 28, 2026.
3 citations
Fire safety inspection on January 21, 2026
CMS lists this as a standard inspection.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on March 4, 2026.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on March 4, 2026.
Citation K0781. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on March 4, 2026.
1 citation
Health inspection on December 2, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
61 of 507 Indiana homes (12%) got a citation at the actual harm level in 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 22, 2025.
CMS has cited this home for F0689 2 times since 2023.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS abuse icon
CMS removed its abuse icon from this home.
1 citation
Health inspection on October 3, 2025
CMS lists this as a complaint inspection.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on October 4, 2025.
CMS has cited this home for F0755 3 times since 2023.
2 citations
Health inspection on September 12, 2025
CMS lists this as a complaint inspection.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 3, 2025.
CMS has cited this home for F0684 3 times since 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on August 22, 2025.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
CMS abuse icon
CMS added its abuse icon to this home.
5 citations
Health inspection on January 17, 2025
CMS lists this as a standard inspection.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 7, 2025.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on February 7, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on February 7, 2025.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on February 7, 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on February 7, 2025.
2 citations
Fire safety inspection on January 17, 2025
CMS lists this as a standard inspection.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on February 13, 2025.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on February 13, 2025.
CMS has cited this home for K0363 2 times since 2023.
CMS update of September 26, 2024
Fine
CMS changed the fine from February 23, 2024 from $24,070 to $15,646.
1 citation
Health inspection on August 1, 2024
CMS lists this as a complaint inspection.
Citation F0602. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from the wrongful use of the resident's belongings or money.
CMS lists it as corrected on July 18, 2024.
CMS has cited this home for F0602 2 times since 2024.
1 citation
Health inspection on May 30, 2024
CMS lists this as a complaint inspection.
Citation F0839. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Employ staff that are licensed, certified, or registered in accordance with state laws.
CMS lists it as corrected on May 18, 2024.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
2 citations
Health inspection on February 23, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
23 of 507 Indiana homes (5%) got a citation at the immediate jeopardy level in 2024.
Citation F0803. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 25, 2024.
Citation F0602. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from the wrongful use of the resident's belongings or money.
CMS lists it as corrected on February 15, 2024.
Fine
February 23, 2024 (2 years ago)
CMS fine of $15,646 on February 23, 2024.
CMS update of January 31, 2024
Fine
CMS changed the fine from September 20, 2022 from $15,000 to $9,750.
2 citations
Health inspection on January 2, 2024
CMS lists this as a complaint inspection.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 26, 2023.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on January 19, 2024.
7 citations
Health inspection on November 20, 2023
CMS lists this as a standard inspection and a complaint inspection.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on December 15, 2023.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on December 15, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 15, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 15, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on December 15, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 15, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 15, 2023.
4 citations
Fire safety inspection on November 20, 2023
CMS lists this as a standard inspection.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on December 28, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on December 28, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on December 28, 2023.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on December 28, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- WITHAM MEMORIAL HOSPITAL5% or greater direct ownership interest · 100% · since 07/01/2015
- RHS PARTNERS OF CARMEL LLCOperational/managerial control · not applicable · since 07/01/2015
- CARMACK, KYLIEOperational/managerial control · not applicable · since 03/06/2023
- HAFIDH, SAADOperational/managerial control · not applicable · since 07/15/2025
Questions
When was Wellbrooke of Carmel last inspected?
CMS lists January 21, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Wellbrooke of Carmel have?
CMS lists 25 health citations since November 20, 2023. CMS also calls these deficiencies.
Has Wellbrooke of Carmel been fined?
CMS lists 1 fine in the past three years, $15,646 in total.
What is the CMS star rating of Wellbrooke of Carmel?
Its CMS overall star rating is 3 of 5.
Is Wellbrooke of Carmel a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.