Wellbrooke Of Carmel
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
WELLBROOKE OF CARMEL in CARMEL, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CARMEL, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WELLBROOKE OF CARMEL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.