Wellbrooke of Kokomo: Fall Unreported for Hours - IN
The incident happened on the night of June 21, 2025. A QMA identified in inspection records as QMA 6 heard a noise and went to check on a resident, but she went to the wrong room. That resident said he hadn't fallen. She reported what she'd heard to LPN 1 anyway, and LPN 1 confirmed the resident she checked said he was fine. Nobody followed up further.
It wasn't until approximately 4:00 a.m. on June 22 that QMA 6 went to Resident C's room to give him his morning medications. He told her his bathroom had flooded from a broken toilet. That's when QMA 6 understood what had happened: Resident C was the one who had fallen the night before. She went to LPN 5 and reported it.
LPN 5 told inspectors he learned about the fall at approximately 5:00 a.m., more than six hours after it occurred. He went to Resident C's room, saw the broken toilet, and completed a fall assessment with neurological checks at that point.
The delay in identifying the right resident wasn't the only problem inspectors documented. Resident C had a bruise on his back noticed after the fall. A staff member identified in the report as Clinical Support 8 told inspectors that bruise was never measured and never tracked the way the facility's own guidelines required. Those guidelines call for a wound nurse or designee to assess any new bruise, enter it into the electronic health record, and monitor it weekly until it resolves.
None of that happened.
LPN 1 told inspectors she had been working Resident C's unit the evening of June 21 but was not assigned to his care that shift. The inspection, conducted August 27, 2025, stemmed from three separate complaints.
Resident C spent a night with an unrecorded fall, a flooded bathroom, and a bruise on his back that no one measured.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
WELLBROOKE OF KOKOMO in KOKOMO, IN was cited for violations during a health inspection on August 27, 2025.
The incident happened 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.