Inspection Reports for Wellbrooke of Avon
12315 PENNSYLVANIA STREET, CARMEL, IN, 46032
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 13, 2025, found Wellbrooke of Avon in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards, with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including care plan development, pressure ulcer prevention, fall hazard management, medication dating, and resident rights, as well as some Life Safety Code issues such as unsecured gas cylinders and smoke barrier door failures. Complaint investigations were mostly unsubstantiated, though a substantiated complaint in May 2024 noted deficiencies involving resident bathing preferences, nursing staff competency, and protection of a resident’s property from misuse by an employee. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to be improving over time, with recent inspections showing correction of prior deficiencies and compliance with key regulatory requirements.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
145% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
67% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 47
Capacity: 70
Deficiencies: 0
Date: May 13, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/02/25 was performed to verify compliance with prior deficiencies.
Findings
At this PSR survey, Wellbrooke of Avon was found in compliance with Requirements for Participation Medicare/Medicaid, Life Safety From Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 43
Capacity: 70
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 04/02/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to properly secure 2 of 6 cylinders of nonflammable gases, which could affect up to 8 staff members.
Deficiencies (1)
Failed to ensure 2 of 6 cylinders of nonflammable gases such as carbon dioxide or oxygen were properly secured from falling.
Report Facts
Certified beds: 70
Census: 43
Number of cylinders improperly secured: 2
Number of cylinders total: 6
Number of staff potentially affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Acknowledged the cylinders were not properly secured and was educated on NFPA 99 requirements | |
| Facility Maintenance Support Director | Participated in the facility tour and exit conference discussing the deficiency |
Inspection Report
Recertification
Census: 41
Capacity: 81
Deficiencies: 5
Date: Mar 7, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00446817.
Complaint Details
Complaint IN00446817 was investigated during this visit. No deficiencies related to the allegations were cited.
Findings
The facility was found to be in substantial compliance with state and federal requirements. No deficiencies related to the complaint were cited. Several deficiencies were noted related to care plan development for recurrent UTIs, pressure ulcer prevention and documentation, fall hazard due to loose shower threshold, late physician documentation, and medication dating.
Deficiencies (5)
Failed to develop and implement a person-centered care plan related to recurrent Urinary Tract Infections (UTI) for a resident who had seven UTIs in a 12-month period.
Failed to ensure appropriate/effective interventions to prevent new pressure ulcers and failed to ensure accurate documentation for 2 residents reviewed for pressure ulcers.
Failed to ensure a resident with a history of falls had an environment free from accident hazards when the rubber threshold of the shower was unattached and loose on the floor.
Failed to ensure Medical Providers entered their visit assessments, summaries, and/or progress notes into the resident's medical records timely for facility staff access, affecting 6 of 13 residents reviewed.
Failed to date medications when opened for 1 of 3 medication carts reviewed.
Report Facts
Survey dates: March 3, 4, 5, 6 and 7, 2025
Census Bed Type Total: 81
Residential Census: 41
Residents affected by late physician notes: 6
Late physician notes count: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachelle Morgan | DHS | Laboratory Director's or Provider/Supplier Representative's Signature on report |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
The inspection was a paper compliance review related to the Recertification and State Licensure Survey completed on March 7, 2025.
Findings
Wellbrooke of Avon was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 70
Deficiencies: 0
Date: Feb 17, 2025
Visit Reason
An investigation of Complaint Number IN00453116 was conducted by the Indiana Department of Health. The complaint survey was conducted to assess compliance with Medicare/Medicaid and related regulations.
Complaint Details
Complaint Number IN00453116 was investigated and no deficiencies related to the allegation were cited.
Findings
At this Complaint survey, Wellbrooke of Avon was found in compliance with Medicare/Medicaid and Emergency Preparedness Requirements. No deficiencies related to the complaint allegation were cited. The facility was also found compliant with Life Safety Code requirements.
Report Facts
Certified beds: 70
Census: 49
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Nov 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439477.
Complaint Details
Complaint IN00439477 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 41
Census Bed Type - SNF: 23
Census Bed Type - SNF/NF: 18
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 13
Census Payor Type - Other: 11
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
Paper compliance review to the Investigation of Nursing Home Complaint IN00434357 completed on May 24, 2024.
Complaint Details
Investigation of Nursing Home Complaint IN00434357; paper compliance review found facility in compliance.
Findings
Wellbrooke of Avon was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the nursing home complaint.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 3
Date: May 23, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00434357 and Residential Complaint IN00428807, focusing on allegations related to resident care and misappropriation of property.
Complaint Details
Complaint IN00434357 involved federal/state deficiencies related to resident care including bathing and nursing staff competency. Complaint IN00428807 involved state deficiencies related to misappropriation of property where an employee used a resident's credit card without consent.
Findings
The facility was found deficient in ensuring resident bathing preferences were met, nursing staff competency in mechanical lift transfers, and protecting a resident's credit card from fraudulent charges by an employee. Deficiencies were cited related to ADL care, competent nursing staff, and residents' rights regarding misappropriation of property.
Deficiencies (3)
Failed to ensure showers were provided according to resident bathing preference for 1 of 1 residents reviewed.
Failed to ensure a nurse aide was competent to safely transfer a resident using a mechanical lift for 2 of 4 residents reviewed.
Failed to ensure a resident's credit card was protected from diversion, resulting in fraudulent charges by an employee for 1 of 3 residents reviewed.
Report Facts
Census: 42
Residents reviewed for mechanical lifts: 4
Residents reviewed for misappropriation: 3
Showers administered: 16
Inspection Report
Life Safety
Census: 49
Capacity: 70
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/07/24 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Wellbrooke of Avon was found in compliance with Requirements for Participation Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety From Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and smoke detectors in all resident sleeping rooms and corridors.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 12, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00414005 completed on February 2, 2024.
Complaint Details
Investigation of Complaint IN00414005 was completed; facility found in compliance.
Findings
Wellbrooke of Avon was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00414005.
Inspection Report
Life Safety
Census: 46
Capacity: 70
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) on 03/07/2024.
Findings
The facility was found not in compliance due to failure of 1 of 7 sets of smoke barrier doors to restrict smoke movement for at least 20 minutes. The doors failed to fully close, leaving a 36 inch gap due to carpet rubbing on the door bottom, potentially affecting 24 residents, 4 staff, and 2 visitors.
Deficiencies (1)
Failed to ensure 1 of 7 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes due to doors not fully closing, leaving a 36 inch gap.
Report Facts
Certified beds: 70
Census: 46
Gap in smoke barrier doors: 36
Residents potentially affected: 24
Staff potentially affected: 4
Visitors potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Minito | Executive Director | Signed the report |
| Director of Plant Operations | Named in relation to the smoke barrier door deficiency and corrective actions |
Inspection Report
Recertification
Census: 84
Deficiencies: 8
Date: Feb 2, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00414005, IN00416689, and IN00426548.
Complaint Details
Complaint IN00414005 had Federal/State deficiencies cited at F684. Complaints IN00416689 and IN00426548 had no deficiencies related to the allegations.
Findings
The facility was found to have deficiencies related to resident rights, care plan timing and revision, quality of care including delayed treatment after a fall with fracture, urinary catheter care, medication labeling and storage, food safety and hand hygiene during dining services, and failure to obtain signed resident rights upon admission.
Deficiencies (8)
Failure to ensure a resident was wearing weather appropriate clothing when leaving the facility.
Failure to implement complete, person centered care plans for advance directive care plans for 4 residents.
Failure to ensure a resident received appropriate and timely treatment after a fall with fracture.
Failure to ensure a Foley catheter bag was kept off the floor for a resident with history of urinary tract infections.
Failure to dispose of a controlled medication after expiration and failure to label medications with expiration dates and resident information.
Failure to appropriately assist a resident with eating and failure to complete correct hand hygiene during dining services.
Failure to ensure residents or family representatives signed a copy of their resident rights upon admission for 4 residents.
Failure to ensure medications were labeled with expiration dates, resident name, and prescription details on medication storage and carts.
Report Facts
Survey dates: January 29, 30, 31, February 1 and 2, 2024
Census: 84
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachelle Morgan | Laboratory Director or Provider/Supplier Representative | Signed report |
| BD 87 | Bus Driver | Named in finding related to resident transported without appropriate outerwear |
| Director of Nursing | Director of Nursing | Named in multiple findings including education and interviews |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in multiple findings including education and interviews |
| RN 78 | Registered Nurse | Replaced Foley bag and provided interview |
| CRCA 25 | Certified Resident Care Assistant | Named in feeding and hand hygiene deficiency |
| DA 55 | Dietary Aide | Named in hand hygiene deficiency |
| RN 85 | Registered Nurse | Named in hand hygiene deficiency |
| Medical Director | Medical Director | Interviewed regarding fall and treatment |
| Social Service Director | Social Service Director | Interviewed regarding family complaints |
| Minimum Data Set Support | MDS Support | Interviewed regarding care plan documentation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 76
Deficiencies: 0
Date: Mar 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00395786, IN00401894, and IN00403548 at Wellbrooke of Avon.
Complaint Details
Investigation of complaints IN00395786, IN00401894, and IN00403548 found no deficiencies related to the allegations; all complaints were unsubstantiated.
Findings
No deficiencies related to the allegations in complaints IN00395786, IN00401894, and IN00403548 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 44
Total Capacity: 76
Survey Dates: 3
Inspection Report
Re-Inspection
Census: 50
Capacity: 70
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/08/22 was performed by the Indiana Department of Health.
Findings
At this Life Safety Code survey, Wellbrooke of Avon was found in compliance with Requirements for Participation Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety From Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 48
Capacity: 83
Deficiencies: 0
Date: Dec 17, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 25, 2022, including a PSR to the Investigation of Complaints IN00392899 and IN00390209 and the State Residential Licensure Survey completed on October 25, 2022.
Complaint Details
Complaint IN00392899 and Complaint IN00390209 were investigated and found to be corrected.
Findings
Wellbrooke of Avon was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00392899 and IN00390209. Both complaints were corrected.
Report Facts
Census Bed Type - SNF/NF: 27
Census Bed Type - SNF: 21
Census Bed Type - Residential: 35
Total Capacity: 83
Census Payor Type - Medicare: 21
Census Payor Type - Medicaid: 17
Census Payor Type - Other: 10
Total Census: 48
Inspection Report
Annual Inspection
Census: 49
Capacity: 70
Deficiencies: 1
Date: Dec 8, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to a wheeled cart obstructing the means of egress in one corridor.
Deficiencies (1)
Facility failed to maintain the means of egress free from obstructions in 1 of 5 corridors; a PVC cart was stored in the corridor, not meeting the criteria for allowed wheeled equipment.
Report Facts
Residents affected: 16
Staff affected: 4
Visitors affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Dent | Executive Director | Facility Administrator present at exit conference |
| Director of Plant Operations | Interviewed regarding the wheeled cart obstruction and educated on NFPA 101 requirements |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 86
Deficiencies: 0
Date: Nov 16, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394081.
Complaint Details
Complaint IN00394081 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00394081 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 51
Total Capacity: 86
Inspection Report
Recertification
Census: 38
Deficiencies: 22
Date: Oct 25, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00392899, IN00390209 and IN00384363.
Complaint Details
Complaint IN00392899 - Substantiated with deficiencies cited at F684. Complaint IN00390209 - Substantiated with deficiencies cited at F677. Complaint IN00384363 - Substantiated with no deficiencies cited.
Findings
The facility was found to have multiple deficiencies including failure to ensure appropriate medication self-administration assessments, failure to report injuries of unknown origin, inaccurate MDS assessments, failure to complete PASRR Level II assessments, failure to revise care plans, failure to provide ADL assistance per resident preferences, failure to provide appropriate care for biliary drainage catheter, failure to ensure neurochecks post fall, failure to prevent moisture associated skin damage, failure to ensure bladder scans and catheterization as ordered, failure to prevent accidents and ensure resident supervision, failure to ensure medication regimens had adequate indications, failure to ensure food safety with proper labeling and expiration, failure to ensure staff COVID-19 vaccination compliance, failure to submit dementia care disclosure form, failure to complete admission assessments and service plans, and failure to secure medications in assisted living.
Deficiencies (22)
Failure to ensure residents were appropriately assessed and monitored for ability to self-administer medications.
Failure to report a new fracture and/or injury of unknown origin to the state as required.
Failure to ensure Minimum Data Set (MDS) assessments accurately reflected resident status.
Failure to ensure a resident received a new PASRR Level II assessment after new mental health diagnoses.
Failure to revise care plans after assessments for residents with urinary issues and other conditions.
Failure to provide ADL assistance according to resident preferences for bathing/showers.
Failure to provide appropriate care and services to prevent complications with biliary drainage catheter resulting in actual harm.
Failure to ensure neurochecks were assessed after a resident fall.
Failure to ensure comprehensive admission assessment to address PICC dressing.
Failure to prevent development of moisture associated skin damage (MASD) and timely assessment of new wounds.
Failure to ensure bladder scans and in/out catheterization as ordered.
Failure to ensure resident environment free of accident hazards and adequate supervision to prevent accidents.
Failure to ensure catheter tubing and drainage bag were kept off the floor to prevent infection.
Failure to ensure all medications were disposed of when expired.
Failure to ensure residents' medication regimens had adequate indication for use.
Failure to ensure food safety by properly labeling and discarding expired food items.
Failure to ensure all staff were fully vaccinated for COVID-19.
Failure to submit Dementia Care Disclosure form to the Indiana Department of Health.
Failure to complete preadmission or admission assessment and evaluation for Assisted Living admission.
Failure to ensure residents with over the counter medications in their apartments had physician orders and medications secured.
Failure to create and review service plans for newly admitted and semi-annual residents in Assisted Living.
Failure to provide adequate pain management resulting in resident in acute pain during wound treatment.
Report Facts
Survey dates: 7
Census: 38
Expired prune juice cups: 12
Residents reviewed for medication indication: 8
Residents reviewed for service plans: 6
Residents reviewed for medication self-administration: 5
Residents reviewed for urinary catheters: 4
Residents reviewed for pressure ulcers: 3
Residents reviewed for accidents: 3
Residents reviewed for pain management: 2
Residents reviewed for medication storage: 5
Residents reviewed for admission assessment: 1
Residents reviewed for dementia care disclosure: 15
Staff vaccination compliance: 1
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