Wellbrooke of Kokomo: Fall Ignored Overnight - IN
The incident at Wellbrooke of Kokomo occurred on the night of June 21, 2025. Inspectors from the Centers for Medicare and Medicaid Services documented what followed during a complaint investigation completed August 27.
A nursing assistant, identified in the report as CNA 2, learned that evening that Resident C had fallen. She went immediately to a licensed practical nurse, LPN 1, and told her a resident had fallen. She had made clear, the report states, which resident she meant.
What happened next was a case of a shared first name undoing everything.
QMA 6, a qualified medication aide, was also told a resident had fallen. The resident she was told about had the same first name as Resident C. She went to that other resident's room to check on him. He said he hadn't fallen. QMA 6 then went back to LPN 1 and reported that she had checked on the resident and he said he did not fall.
Nobody went to Resident C's room that night.
LPN 1, in a phone interview with inspectors on August 27, confirmed she was working Resident C's unit that entire shift, from 10 a.m. to 10 p.m. She was not, she said, assigned to his care during that shift.
Resident C spent the night alone in a room with a broken toilet and a flooded bathroom floor.
At approximately 4 a.m. on June 22, QMA 6 entered Resident C's room to give him his morning medications. He told her his bathroom had been flooded with water from his toilet. That was the moment, the inspection report states, that QMA 6 realized Resident C was the resident who had fallen the night before. She went to LPN 5 and reported it.
LPN 5, in a phone interview with inspectors, said he was notified around 5 a.m. that Resident C had fallen at 10:30 the previous night. He went to the room, saw the broken toilet, and completed a fall assessment with neurological checks at that time, roughly six and a half hours after the fall occurred.
The delay in confirming the fall was not the only problem inspectors documented.
A bruise on Resident C's back, noticed after the fall, was never properly tracked. Clinical Support 8 told inspectors on August 27 that the bruise had not been measured or followed in accordance with the facility's own guidelines. Those guidelines require that when a skin change occurs, an assessment be completed in the electronic health record by a nurse, that a wound nurse conduct a follow-up assessment, and that the injury be monitored weekly for at least one week until it is determined to be healing, resolved, or chronic.
None of that happened for the bruise on Resident C's back.
The facility's bruise assessment policy had been in place since May 2016. Clinical Support 8 provided a copy of it to inspectors during the investigation.
The inspection report classified the violation under F0684, which covers the standard of care residents are entitled to receive, and listed the level of harm as minimal harm or potential for actual harm, with few residents affected. The citation was tied to three separate complaint intakes filed with regulators.
What the report does not say is how Resident C fared through the night, what the bruise on his back looked like by morning, or whether anyone asked him how he had managed to get himself back into his wheelchair after breaking a toilet and flooding his own bathroom floor.
He had done all of that alone. The towels were still there when someone finally came.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wellbrooke of Kokomo from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
WELLBROOKE OF KOKOMO in KOKOMO, IN was cited for violations during a health inspection on August 27, 2025.
The incident at Wellbrooke of Kokomo occurred on the night of June 21, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.