Wellbrooke of Carmel

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's representative and physician were notified when a resident's weight was obtained, documented, and showed a loss for 1 of 2 residents reviewed for notification of change. (Resident 23)

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Record Review (PASARR) was accurate for a resident with mental health diagnoses for 1 of 2 residents reviewed for PASARR. (Resident 14)

Inspectors wroteBased on interview and record review, the facility failed to ensure tuberculosis tests were administered according to the acceptable standard of practice for 2 of 5 residents reviewed for infection control. (Resident 1 and 62)

Inspectors wroteBased 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.

Inspectors wroteBased 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)

Inspectors wroteBased on interview and record review, the facility failed to ensure pain assessments were completed prior to and after the administration of narcotic pain medication for 2 of 3 residents reviewed for quality of care. (Resident B and C)

Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic pain medications were documented as administered on the medication administration record for 2 of 3 residents reviewed for controlled medications. (Resident B and C) The deficient practice was corrected on 8/22/25, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's code status was changed when an out of hospital do not resuscitate declaration and order was received for 1 of 3 residents reviewed for advanced directives. (Resident 9)

Inspectors wrote2. The clinical record for Resident 29 was reviewed on 1/14/25 at 3:29 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, insomnia, and visual hallucinations. A review of the Resident First Meeting Minutes indicated the facility had not conducted a care plan meeting for Resident 29 since 5/30/24. The resident had not had a quarterly care plan meeting held since that time. A nursing progress note, dated 10/11/24, indicated Resident 29 had been experiencing intermittent hallucinations. A psychiatry note, dated 10/16/24, indicated Resident 29 had been experiencing visual hallucinations since her husband's death in April 2024. The hallucinations had started to occur more frequently, and Resident 29 was started on Risperidone (an antipsychotic medication) for the visual hallucinations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a blood pressure medication was held according to the physician's ordered hold parameter and to ensure the physician was notified for an elevated blood sugar level according to the call parameter for 3 of 3 residents reviewed for quality of care. (Resident 194, 4 and 2)

Inspectors wrote2. The clinical record for Resident 1 was reviewed on 1/14/25 at 3:32 p.m. The diagnoses included, but were not limited to, sepsis (a life-threatening complication of an infection), urinary tract infection (UTI), urethral stricture (a condition which blocks the flow of urine), and urinary retention. A physician's order indicated Resident 1 had a suprapubic catheter (a tube which drains urine directly from the bladder through a small incision in the lower abdomen) due to urethral stricture. A physician's order, dated 5/16/24, indicated to monitor Resident 1's urinary output three times a day, every shift. A Treatment Administration Record (TAR), dated 12/1/24 through 1/15/25, indicated the following documented urinary outputs: On 12/1/24 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 12/1/24 between 2:00 p.m. to 10:00 p.m., medium was recorded. On 12/3/24 between 6:00 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medication administration or reason medication was not given was documented in the Medication Administration Record for 1 of 7 residents reviewed for documentation. (Resident 30)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's credit card was kept safe and secure during her admission for 1 of 3 residents reviewed for misappropriation of property. (Resident B) The deficient practice was corrected on 7/18/24, prior to the start of the survey, and therefore was past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member had the appropriate qualifications and current certification to perform the duties of a Certified Nursing Assistant (CNA) and a Qualified Medication Aide (QMA) during the 34 day time period he was hired at the facility and failed to ensure a job specific orientation checkoff list for his CNA was completed and signed by the trainer prior to working alone on the floor as a CNA for 1 of 5 employees reviewed. (Employee 1) The deficient practice was corrected on 5/18/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased 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 1/24/24, 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. The Executive Director (ED), Director of Health Services (DHS), and the Clinical Support Nurse were notified of the immediate jeopardy on 2/23/24 at 11:48 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from misappropriation of property, specifically medications, when the facility discovered the resident was missing 12 oxycodone (a narcotic) from the narcotic box for 1 of 3 residents reviewed for misappropriation of property. (Resident C) The deficient practice was corrected by 2/15/24 prior to the start of survey and was therefore past noncompliance.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from verbal abuse when a staff member was heard speaking to a resident loudly and using profanity for 1 of 3 residents reviewed for abuse. (Resident 2) This deficient practice was corrected on 12/26/23, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide toileting assistance when a resident had asked for assistance to use the toilet for 1 of 1 resident reviewed for Activities of Daily Living (ADL) care. (Resident 3)

Inspectors wroteBased on record review and interview, the facility failed to ensure the discharge MDS (Minimum Data Set) assessment was coded correctly for 1 of 1 resident reviewed for hospital discharge. (Resident 54)

Inspectors wroteBased on record review and interview, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) Level I had accurate information and a Level I was completed when residents had an added mental health diagnosis and psychotropic medications prescribed for 2 of 2 residents reviewed for PASARR. (Resident 38 and 20)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received the correct dosage of a narcotic for 1 of 1 resident reviewed for quality of care. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to implement timely interventions after a fall with a stand-up lift which resulted in another fall with a stand-up lift for 1 of 4 residents reviewed for falls. (Resident 33)

Inspectors wroteBased on interview and record review, the facility failed to obtain an admission weight upon admission and to obtain a timely reweight after the weight was determined to be invalid for 1 of 3 residents reviewed for nutrition. (Resident 13)

Inspectors wroteBased on observation and interview, the facility failed to dispose of loose pills and have opened dates on medications in 2 of 3 medication carts and 1 of 1 medication room reviewed for medication storage. (Keystone front cart, Keystone medication room and Brickshire medication cart)

Inspectors wroteBased on record review and interview, the facility failed to identify the time frame for the consideration of a gradual dose reduction (GDR) with the use of psychotropic medications and to identify resident specific reasons for the declining of gradual dose reductions for 3 of 5 residents reviewed for unnecessary medications. (Resident 38, 33 and 34)