Wellbrooke Of Carmel
WELLBROOKE OF CARMEL in CARMEL, IN — inspection on October 3, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on interview and record review, the facility failed to ensure a resident was ordered and provided with the proper dose of a medication for 1 of 3 residents reviewed for pharmaceutical services. (Resident B)Findings include:The clinical record for Resident B was reviewed on 10/2/25 at 10:13 a.m.
The diagnoses included, but were not limited to Parkinson's disease, history of stroke, and weakness.A physician's order, dated 8/11/25 and discontinued 8/12/25, indicated to administer Rytary (a medication used to treat symptoms of Parkinson's disease) extended release 48.75-195 milligrams (mg) one (1) capsule four (4) times per day.A physician's order, dated 8/12/25 and discontinued 8/30/25, indicated to administer Rytary extended release 48.75-195 mg four (4) capsules four (4) times per day.A physician's order, dated 8/30/25 and discontinued 9/11/25, indicated to administer Rytary extended release 48.75-195 mg one (1) capsule four (4) times per day.Resident B admitted to the assisted living section of the facility on 9/11/25.A physician's order, dated 9/11/25 and discontinued 9/17/25, indicated to administer Rytary extended release 48.75-195 mg one (1) capsule four (4) times per day.A physician's order, dated 9/17/25 and discontinued 10/1/25, indicated to administer Rytary extended release 48.75-195 mg two (2) capsules four (4) times per day.
During an interview, on 10/2/25 at 11:40 a.m., the Director of Nursing (DON) indicated the resident was supposed to receive four (4) capsules instead of 1 capsule. A weekend nurse had questioned the medication dosage, and when pharmacy looked at the dosage, they changed the medication back to one (1) capsule four (4) times per day.
During an interview, on 10/2/25 at 2:00 p.m., the DON indicated the admitting nurse had incorrectly entered the order for one (1) capsule and had quickly changed it back to the correct dosage of four (4) capsules.
When the pharmacy reviewed the medication, on 8/30/25, they had looked at an older resident profile which led to the pharmacy changing the order back to one (1) capsule which was an incorrect dosage.
When the issue was finally caught, the physician ordered the Rytary for two (2) capsules to titrate Resident B back up to the correct dose.An email from the Executive Director (ED), on 9/22/25 at 3:40 p.m., indicated, on 8/30/25, the weekend supervisor was verifying orders and had spoken to the pharmacist regarding the medication.
The pharmacist reported the medication dosage should be changed from four (4) capsules to one (1) capsule.
The facility indicated the pharmacy may have looked at an older profile for Resident B.
During an interview, on 10/3/25 at 10:45 a.m., Clinical Support Nurse 1 indicated if the facility requested an immediate pharmacy review, they expected the pharmacy would had reviewed the medications and gave recommendations accurately.A current facility policy, titled CONSULTANT PHARMACIST REPORTS, dated as last revised in November 2018 and received from Clinical Support Nurse 1 on 10/3/25 at 10:30 a.m., indicated .Pharmacy will provide facilities with an Immediate Medication Regimen Review (IMRR) upon request.The facility may request that a licensed pharmacist perform an IMRR.This citation relates to Intake 2628099.3.1-25(e)(1)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.