Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Wellbrooke Of Kokomo during CMS and state inspections, most recent first.
A resident’s MDS assessment omitted active cancer diagnoses, including breast cancer, ovarian cancer, and metastatic brain cancer, even though the clinical record documented those conditions. The Clinical Support Nurse stated the MDS should have included the cancer diagnoses and that a care plan should have been in place, and an RN later confirmed the diagnoses were not entered on the MDS.
A resident with CHF, type 2 DM, and metastatic brain cancer did not have comprehensive person-centered care plans in the record for CHF/diuretic use, diabetes/insulin use, or brain metastasis/antipsychotic use. An LPN, the Clinical Support Nurse, and an RN all stated care plans should have been in place, and the facility policy required comprehensive care plans within 7 days of the admission comprehensive assessment and kept current.
Failure to Follow Medication Parameters and Complete AIMS Assessment: The facility administered ordered BP medications outside prescribed hold parameters for two residents, including hydralazine and metoprolol given when systolic BP was below the ordered limits. The facility also did not complete an AIMS assessment for a resident receiving quetiapine for brain metastasis, and staff acknowledged the assessment was missing.
Compromised controlled substance cards were found in a medication cart, including oxycodone for a resident who had already discharged and Norco for another resident with a slit in the card. Staff, including a QMA, RN, and DON, stated narcotic cards should not be taped or altered and that discontinued narcotics should be destroyed rather than left in the cart.
Infection control failures were observed involving improper PPE use during catheter care, lack of precaution signage and orders for a resident with a PICC line and VRE, and improper medication handling when an LPN placed a dropped pill into a med cup before later destroying it. Staff interviews confirmed the gown was not tied correctly, and the DON stated the resident should have been on contact precautions or EBP and that dropped pills should be destroyed.
Two residents with significant respiratory and cardiac conditions were observed receiving oxygen at a higher flow rate than ordered by their physicians. Staff interviews and facility policy confirmed that oxygen should be administered as prescribed, but observations showed both residents received 3 L/min instead of the ordered 2 L/min via nasal cannula.
MDS Assessment Omitted Active Cancer Diagnoses
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to include active cancer diagnoses on the Minimum Data Set (MDS) assessment for Resident 4. The clinical record showed diagnoses of malignant neoplasm of the breast, malignant neoplasm of the ovary, and metastatic brain cancer, but the MDS assessment dated 1/23/26 did not include the cancer diagnoses. During interview, the Clinical Support Nurse stated the MDS should have included the cancer diagnoses and that a care plan should have been in place. RN 12 later confirmed the cancer diagnoses were not included on the MDS assessment dated [DATE]. The facility also reported it did not have a policy for MDS accuracy and followed the RAI manual.
Incomplete Care Plan for Resident with CHF, Diabetes, and Metastatic Brain Cancer
Penalty
Summary
Comprehensive person-centered care plans were not developed and implemented for Resident 4, who had diagnoses including congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer. The clinical record showed physician orders for furosemide 40 mg twice daily, quetiapine 25 mg daily for brain metastasis, and insulin lispro per sliding scale before meals and at bedtime, but the record did not contain care plans related to congestive heart failure and diuretic use, diabetes and diabetic medication use, or metastatic brain cancer and antipsychotic use. During interviews, an LPN, the Clinical Support Nurse, and an RN each stated the resident should have had care plans in place for congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer. The facility policy titled Comprehensive Care Plan Guidelines stated that comprehensive care plans are to ensure appropriateness of services and communication to meet the resident's needs and are to be developed within 7 days of the admission comprehensive assessment, and that comprehensive care plans need to remain accurate and current.
Failure to Follow Medication Parameters and Complete AIMS Assessment
Penalty
Summary
The facility failed to follow physician-ordered medication parameters for two residents. One resident with diagnoses including sepsis, cardiomyopathies, combined systolic and diastolic heart failure, and hypertensive heart disease with heart failure had an order for hydralazine 100 mg three times daily with instructions to hold the medication if systolic blood pressure was less than 140. The MAR showed hydralazine was administered on multiple occasions when the systolic blood pressure was below 140, including readings of 133, 121, 128, 131, 114, 138, 111, and 118. Another resident with diagnoses including paroxysmal atrial fibrillation, COPD, chronic diastolic heart failure, and hypertensive heart and chronic kidney disease with heart failure had an order for metoprolol succinate 25 mg at bedtime with instructions to hold if systolic blood pressure was less than 110, yet the MAR showed the medication was given when systolic blood pressure was 107, 106, and 108. The facility also failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident with malignant neoplasm of the breast, malignant neoplasm of the ovary, and metastatic brain cancer who had an order for quetiapine 25 mg daily for brain metastasis. No AIMS assessment was located in the clinical record. Facility staff acknowledged that the assessment had not been completed and should have been completed, and staff stated that residents on psychotic medication should have an AIMS assessment completed upon admission and quarterly.
Compromised Controlled Substance Cards Left in Medication Cart
Penalty
Summary
The facility failed to ensure controlled substance medications were destroyed when they were compromised or no longer in use in the 100-hall front medication cart. During observation, a card of oxycodone 5 mg tablets for a resident who had discharged from the facility was still stored in the cart, and clear tape covered the back of the number 4 and 5 slots. A second controlled substance card, Norco 10/325 mg tablets for another resident, had a slit on the back of the card in the number 4 slot. During interview, a QMA stated that when narcotic medications were discontinued, the nurse and DON would destroy the medication and not leave it in the cart. An RN stated the substance control cards should not be taped or have slits on the back. The DON stated staff should not tape the backs of narcotics cards, that the pills needed to be destroyed, and that the medication could be a different pill. The facility policy on disposal of controlled drugs stated disposal should occur immediately, but no longer than three business days after discontinuation of use, and the medication storage policy stated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are to be immediately removed from inventory.
Infection Control and PPE Failures
Penalty
Summary
The facility failed to ensure staff wore personal protective equipment correctly during catheter care for a resident with a catheter. During an observation, a CNA and the ADON prepared to provide catheter care to Resident 3 and both put on gowns and gloves, but they tied only the top of the gowns and did not fasten the waist ties. During the care, the CNA’s gown opened and her clothes touched the resident’s bed and blankets. In interviews, the ADON and CNA acknowledged the gowns were not tied correctly, and the DON stated gowns and gloves needed to be worn in isolation rooms and the gowns should be tied in the back. The facility’s PPE guideline stated the gown should be secured at the neck and waist. The facility also failed to follow infection control orders and medication handling practices for other residents. For Resident 32, who had diagnoses including UTI, VRE, and metabolic encephalopathy and had a PICC line and an order for IV Linezolid, no physician’s order for contact precautions or enhanced barrier precautions was found in the record, and no precaution sign was posted at or around the room; only gloves were observed in the room. The DON stated the resident should have had enhanced barrier precautions for the PICC line and contact precautions for VRE. In another observation, an LPN dropped a pill on the medication cart while preparing medication for Resident 74, placed the pill in the medication cup, and entered the resident’s room before later destroying the pill after the observation was stopped. The DON stated staff should destroy any pills dropped on the cart or anywhere.
Failure to Administer Oxygen at Physician-Ordered Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen was administered at the correct physician-ordered flow rate for two residents. In both cases, observations revealed that the residents were receiving oxygen at 3 liters per minute (L/min) via nasal cannula, while the physician's orders specified a continuous flow of 2 L/min. The first resident had diagnoses including chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia, acute respiratory infection, and respiratory syncytial virus. The second resident's diagnoses included hypertensive heart disease with heart failure, acute on chronic diastolic congestive heart failure, chronic respiratory failure with hypoxia, emphysema, pulmonary fibrosis, and shortness of breath. Interviews with facility staff, including the DON and an LPN, confirmed that oxygen should be administered according to the physician's order and that staff are expected to verify the prescribed flow rate. Review of the facility's policy on oxygen administration also indicated that staff should verify the physician's order and adjust the oxygen delivery device to ensure the proper flow is administered. Despite these expectations and policies, the observed oxygen flow rates did not match the physician's orders for the two residents.
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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) |
|---|---|---|---|---|
| Kokomo Healthcare Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Brickyard Healthcare -sycamore Village Care Center | 1.9 mi | ★★★★★ | 10 | 0 |
| North Woods Village | 2.1 mi | ★★★★★ | 7 | 0 |
| Aperion Care Kokomo | 2.2 mi | ★★★★★ | 1 | 0 |
| Waterford Place Health Campus | 2.3 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.