Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kokomo Healthcare Center during CMS and state inspections, most recent first.
The facility failed to timely destroy discontinued controlled substances, keep them accounted for while stored in the DON’s locked office drawer, and ensure an ordered medication was delivered and given in a timely manner. Multiple narcotic cards and doses remained in storage after discontinuation, some were later reported stolen while awaiting destruction, and an ordered prednisone course for a resident with COPD exacerbation was not given when the pharmacy had not delivered it and no follow-up was documented.
Discontinued controlled substances were stolen from the DON’s office after a former unit manager entered the building, locked herself in the DON’s office, and was heard going through drawers and papers before leaving. Three narcotic cards tied to residents’ discontinued orders were stored in a locked box in the DON’s desk pending destruction, and staff interviews showed the facility kept these meds in the DON’s office until the DON and another nurse could destroy them, without daily counting while stored there.
Failure to notify the ombudsman of a resident hospitalization and failure to document that the bed hold policy was provided to two residents at transfer. One resident was sent out after being found face down in front of a wheelchair, and two other residents were transferred to the hospital/ER with serious medical conditions, but the record lacked evidence that bed hold information was provided or completed, and the ombudsman was not listed on the monthly notification log.
Failure to Notify Physician of Elevated BG Readings: A resident with DM, HTN, anxiety, depression, visual loss, and CKD had a physician order for BG checks BID and to notify the MD if BG was <70 or >150. The MAR showed multiple BG readings above 150 over two months, but there was no documentation that the physician was notified, and the Support Administrator confirmed the lack of notification documentation.
The facility failed to ensure the outdoor patio concrete was even, leading to safety concerns for residents, including one who fell and hit his head. Residents and family members reported difficulties navigating the uneven surface, and staff confirmed the issue. The facility did not provide an environmental policy.
A resident with a history of alcohol abuse returned to the facility appearing intoxicated and was administered temazepam without physician notification. The resident, who later fell and refused neurological checks, had a bruise on her face. Facility policies on medication administration and resident safety were not followed, as the Director of Nursing acknowledged the medication should have been held.
The facility failed to ensure accurate physician's orders for oxygen use, correct oxygen flow rates, and proper labeling and dating of oxygen tubing for four residents. Observations revealed incorrect equipment settings and unlabeled tubing, with staff showing a lack of knowledge and adherence to orders and policies.
The facility failed to complete assessments and obtain physician's orders and consents before using side rails for two residents. Both residents had side rails in use without the required documentation and approvals, contrary to the facility's policy.
A facility failed to renew a PRN lorazepam order after 14 days for a resident with anxiety and depressed mood, despite policy requirements for reevaluation and documentation by the prescribing practitioner. The resident received lorazepam on multiple occasions without the necessary renewal.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to ensure discontinued controlled substances were disposed of in a timely manner, failed to keep controlled substances accounted for while they were waiting to be destroyed, and failed to ensure an ordered medication was provided in a timely manner for 11 of 11 residents reviewed for pharmacy services. During observation and interview, the DON showed that discontinued narcotic cards were being stored in a small locked box inside the bottom drawer of her desk in her office, with the spare key kept in a safe in the same office. Several narcotic medication cards were found locked in that box with reconciliation sheets attached. Record review showed multiple residents had controlled substances that remained in the facility for days or weeks after discontinuation before destruction. Examples included oxycodone, hydrocodone-acetaminophen, tramadol, morphine sulfate ER, fentanyl patches, morphine sulfate concentrate, and lorazepam. In several cases, destruction occurred days after the medication was discontinued, and in other cases the medication was removed from the cart and then stored in the DON’s locked desk drawer until destruction. For some cards, the facility documented that the medication was reported stolen while stored in the DON’s office waiting to be destroyed. The DON and an administrative support nurse stated the facility’s process was to remove discontinued controlled substances from the carts and keep them in the DON’s office until the DON and another nurse could destroy them, and they acknowledged the medications were not counted while stored there. The record for another resident showed prednisone ordered after return from the hospital for COPD exacerbation and pulmonary effusion, but the medication was not administered on the documented dates because it was on order from the pharmacy. There was no documentation that the pharmacy was contacted for follow-up when the medication was not delivered. The DON stated the medication was later reordered and administered for four days. Facility policy required medication documentation to be current, physician contact for critical medications refused or not given, pharmacy contact for changes, and controlled substances to be counted and accounted for at all times with two nurses involved in disposal.
Discontinued controlled substances were stolen from the DON’s office
Penalty
Summary
The facility failed to ensure discontinued controlled substances were free from theft after a former employee entered the building, went into the DON’s office, and removed three discontinued controlled substance prescriptions that were being stored there pending destruction. The DON kept discontinued controlled substances in a locked box inside her desk drawer, with the spare key stored in a safe in her office. During observation, the DON opened the locked drawer and removed a small locked box containing several narcotic cards and reconciliation count sheets, including seven narcotic medication cards stored in the desk drawer. A facility incident report stated that staff heard the former unit manager in the DON’s office going through drawers and papers, and that she refused to leave when asked. Staff reported hearing the door alarm and noises from the office, and multiple witnesses stated the former unit manager was seen in the office and later leaving the building. The facility reported that three discontinued controlled substance prescriptions were missing from the double-locked medication storage in the office after the incident. Record review showed the missing controlled substances were associated with Resident 9, Resident 32, and Resident 56. Resident 9 had a discontinued hydrocodone-acetaminophen order; Resident 32 had a tramadol order; and Resident 56 had a discontinued hydrocodone-acetaminophen order. The facility’s controlled substance tracker showed the cards had been removed from the medication cart for destruction and then stored in the DON’s locked desk drawer waiting to be destroyed. Staff interviews indicated the facility’s process was to remove discontinued controlled substances from the cart and keep them in the DON’s office until the DON and another nurse destroyed them, and that the medications were not counted while stored in the office.
Failure to Notify Ombudsman and Document Bed Hold Policy
Penalty
Summary
The facility failed to ensure the ombudsman was notified of a resident’s hospitalization for one resident who was found face down in front of her wheelchair and sent to the emergency room after a physician’s order was received. The resident’s clinical record showed diagnoses including hypertensive heart disease with heart failure, stage 4 chronic kidney disease, and a history of stroke. The June ombudsman notification log did not list the resident, and the Social Services Director stated she was responsible for notifying the ombudsman by sending the notification on the first of the month for the prior month; if a resident’s name was not listed, the ombudsman was not notified. The facility also failed to document that a bed hold policy was provided to two residents at the time of transfer. One resident with diagnoses including hypertension, heart failure, and type 2 diabetes had a nursing note indicating a large amount of blood was found under the resident’s leg in bed, after which the physician was called and the resident was sent to the hospital; the electronic record had no documentation that a bed hold policy was provided, and the bed hold authorization form was blank where the resident or representative signature should have been and did not indicate whether the bed was to be held. Another resident with malnutrition, weakness, anxiety, COPD, anemia, hypothyroid, tongue cancer, depression, dysphagia, psychoactive substance abuse, and gastrostomy status was sent to the ER for decreased level of consciousness and low oxygen levels and was admitted for aspiration pneumonia; the acute transfer letter had a blank resident signature with a note that the resident was unable to sign due to decreased responsiveness, and there was no documentation in the electronic record that a bed hold policy was provided to the resident or representative at the time of transfer or thereafter.
Failure to Notify Physician of Elevated Blood Glucose Readings
Penalty
Summary
The facility failed to ensure the physician was notified of Resident 31’s blood glucose readings according to the physician’s order. Resident 31 had diagnoses including diabetes mellitus, hypertension, major depressive disorder, visual loss in both eyes, anxiety disorder, and chronic kidney disease. The care plan directed staff to obtain blood sugars per physician order and report abnormal findings to the physician, resident, and resident’s representative. A physician’s order dated 1/6/25 directed blood glucose checks twice daily and notification of the physician if the reading was less than 70 or greater than 150. Review of the MAR for 7/1/25 through 7/31/25 showed multiple blood glucose readings above 150 without physician notification, including readings of 168, 159, 160, 168, 162, 177, and 158. Review of the MAR for 8/1/25 through 8/31/25 showed additional readings above 150 without physician notification, including 153, 185, 151, 158, 151, and 153. During interview, the Support Administrator stated there was no documentation that the physician was notified of blood glucose readings above 150. The facility policy titled Physicians Orders stated to accurately document physician and provider orders, notify attending or other providers as appropriate, and document contacts in the medical record.
Uneven Patio Concrete Poses Safety Risk for Residents
Penalty
Summary
The facility failed to maintain a safe and even outdoor patio area, resulting in safety concerns for residents and their family members. During a resident council interview, two residents expressed concerns about the uneven concrete, noting that other residents had tripped over it. One resident, who uses a wheelchair, tipped backwards and hit his head while attempting to navigate the uneven surface. Observations confirmed the presence of multiple uneven areas in the patio. The clinical record for the resident who fell indicated that he had multiple health conditions, including the absence of both legs below the knee, and used a manual wheelchair for mobility, requiring substantial assistance. Additionally, a family member of another resident reported that her father's legs would sometimes drop off his wheelchair foot pedals when encountering the uneven concrete. A staff member acknowledged that residents occasionally had trouble with the uneven surface, and the Executive Director confirmed the issue during a facility tour. The facility did not provide an environmental policy and stated they followed state regulations.
Failure to Notify Physician Before Administering Medication to Intoxicated Resident
Penalty
Summary
The facility failed to notify the physician before administering medication to a resident suspected of being intoxicated. Resident 53, who has a history of alcohol abuse, was observed with a bruise on her face and reported a fall she could not remember. The resident's clinical record included diagnoses such as moderate protein calorie malnutrition, anemia, major depressive disorder, opioid abuse, alcohol abuse, and anxiety. A physician's order was in place to administer temazepam at bedtime and to monitor for side effects like sedation and increased falls. On the evening of the incident, the resident returned from a leave of absence appearing intoxicated, and the temazepam was administered without notifying the physician of her condition. The resident was found on the floor with signs of intoxication and refused neurological checks after hitting her head. Despite the staff's observation of the resident smelling of alcohol and appearing intoxicated, there was no documentation of physician notification before administering the temazepam. The Director of Nursing later indicated that the medication should have been held if the resident was intoxicated. Facility policies emphasized the importance of avoiding adverse effects and safeguarding residents under the influence, but these were not adhered to in this instance.
Failure to Ensure Accurate Oxygen Administration and Equipment Settings
Penalty
Summary
The facility failed to ensure accurate physician's orders for the use of oxygen, correct oxygen flow rates, and proper labeling and dating of oxygen tubing for four residents. For Resident 118, the Easy Air compressor and oxygen concentrator settings were incorrect, and there was confusion among staff regarding the correct settings. The physician's order was not clear, leading to inconsistent oxygen administration. The DON had to intervene to correct the settings, and it was noted that the staff should have known how to set the equipment according to the physician's order. Resident 20 was observed wearing oxygen with unlabeled nasal cannula tubing on multiple occasions. The physician's order indicated the need for continuous oxygen at 2 liters per minute and for the tubing to be changed and labeled every Monday night shift. However, the tubing was not labeled as required. Similarly, Resident 23 was observed with unlabeled nasal cannula tubing and inconsistent oxygen flow rates. The physician's order specified continuous oxygen at 2 liters per minute and weekly tubing changes, but these instructions were not followed. Resident 43 was also observed with unlabeled nasal cannula tubing and an incorrect oxygen flow rate. The physician's order indicated continuous oxygen at 2 liters per minute and weekly tubing changes, but the tubing was not labeled, and the flow rate was set incorrectly. The facility's policies on continuous aerosol therapy and supplemental oxygen were not adhered to, resulting in these deficiencies. Staff interviews revealed a lack of knowledge and adherence to the physician's orders and facility policies regarding oxygen administration and equipment settings.
Failure to Obtain Assessments and Consents for Bed Rails
Penalty
Summary
The facility failed to ensure that assessments were completed and physician's orders and consents were obtained prior to the use of side rails for two residents. Resident 117 had two upper side rails in the raised position without a side rail assessment or consent in the electronic record. The physician's order for the side rails was completed after the side rails were already in use. The care plan was updated to include the side rails only after the physician's order was obtained. The Clinical Support Nurse confirmed that the side rail assessment was not completed until after the side rails were utilized, and the informed consent was signed without a date to show when it was signed. Similarly, Resident 118 had two upper side rails with the left side rail in the raised position without a side rail consent or assessment in the electronic record. The physician's order for the side rails was obtained after the side rails were already on the resident's bed. The Clinical Support Nurse confirmed that the resident did not have a side rail assessment or consent completed until after the side rails were applied. The facility's policy on the safe use of bed rails requires a physician's order, assessment, consent, and education prior to the use of bed rails, which was not followed in these cases.
Failure to Renew PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to ensure a PRN psychotropic medication was renewed after 14 days for a resident with multiple diagnoses, including adjustment disorder with mixed anxiety and depressed mood, vascular dementia, and cognitive communication deficit. The resident had a care plan indicating mood problems related to anxiety and depressed mood, with interventions to monitor and record mood changes. A physician's order dated 5/1/24 prescribed lorazepam concentrate 2mg/ml to be given by mouth every 4 hours as needed. The Medication Administration Record (MAR) showed the resident received lorazepam on 5/14/24, 5/15/24, and 5/16/24. During interviews, the Director of Nursing (DON) and the Clinical Support Nurse confirmed that PRN lorazepam orders needed a 14-day stop date, requiring reevaluation by the physician for continued use. The facility's policy on antipsychotic medication orders also stipulated a 14-day limit for PRN use, necessitating a face-to-face assessment and documentation by the prescribing practitioner. The failure to renew the PRN lorazepam order after 14 days led to the deficiency identified in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kokomo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Kokomo | 0.8 mi | ★★★★★ | 1 | 0 |
| Wellbrooke Of Kokomo | 1.6 mi | ★★★★★ | 11 | 0 |
| North Woods Village | 2.8 mi | ★★★★★ | 7 | 0 |
| Brickyard Healthcare -sycamore Village Care Center | 3 mi | ★★★★★ | 10 | 0 |
| Waterford Place Health Campus | 3 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.