Waterford Place Health Campus
WATERFORD PLACE HEALTH CAMPUS in KOKOMO, IN — inspection on February 2, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
for services as needed.
Screening and Resident Review) was completed when the resident had a new mental health diagnosis
4)Findings include:The clinical record for Resident 4 was reviewed on 1/28/26 at 12:27 p.m.
The diagnoses included, but were not limited to, depression, atrial fibrillation, heart disease, vascular dementia, pseudobulbar affect, post-traumatic stress disorder (PTSD), and adjustment disorder with anxiety.A physician's order, dated 9/19/25, indicated to administer diazepam (an antianxiety medication) 2 mg (milligram) twice a day. A PASARR level I screen related to the diagnosis of anxiety disorder, and the new medication was not completed until 2/2/26 after the start of the survey.During an interview, on 2/2/26 at 3:39 p.m., the Administrator indicated when a resident had a new psychotic medication or a new mental health diagnosis added, a new level I needed to be completed.
The resident did not have a new level I completed until 2/2/26 to add the diazepam. A current facility policy, titled PASARR Quick Sheet, undated and received from Clinical Support on 2/2/26 at 1:39 p.m., indicated .New Admissions: If any of the following triggers a positive response.contact the PASARR office .Individual has a severe mental illness/behavioral health (BH) diagnosis. ex.
Schizophrenia, Bipolar Disorder, Major Depression Disorder, Anxiety Disorder .These diagnoses must be given by a Psych MD/ARNP and not by a PCP or some other type of treatment provider other than psychiatry 3.1-16(d)(1)(A)3.1-16(d)(1)(B)
155678 02/02/2026
Waterford Place Health Campus 800 St Joseph Dr Kokomo, IN 46901
observation and data collection addresses each body system and shall be initiated within 12 hours
A current facility policy, titled Clinical Services - Weight Monitoring, dated as last reviewed 7/3/25
policy is to ensure weight monitoring to promote well-being of the residents we serve and requires a multidisciplinary approach .Daily review of missing admission weights in CCM .May be reviewed by clinical leaders .Provide a list of missing weights to floor staff to obtain .Review of missing weights: Daily Weights as ordered .May be delegated to clinical leaders .Provide a list of missing monthly weights to floor staff to obtain .Review of error weights, daily, in CCM 3.1-37(a)
155678 02/02/2026
Waterford Place Health Campus 800 St Joseph Dr Kokomo, IN 46901
During an interview, on 1/30/26 at 11:21 a.m., the Medical Record Nurse indicated the catheter bag was not supposed to be on the trash can and the resident was at risk of infection.
During an interview, on 1/30/26 at 11:30 a.m., Qualified Medical Assistant (QMA) 6 indicated the catheter bag should be hung on the bed rail and never on the trash can.
When you hang the bag on the dirty trash can, the resident would be at risk of developing a major infection. A current facility policy, titled Urinary Catheter Care, dated as last reviewed 12/16/24 and received from the Clinical Support nurse on 2/3/26, indicated .Check the urine for unusual appearance .The urinary drainage bag should be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks 3.1-41(a)(2)
155678 02/02/2026
Waterford Place Health Campus 800 St Joseph Dr Kokomo, IN 46901
During an interview, on 1/30/26 at 11:21 a.m., the Medical Record Nurse indicated the catheter bag was not supposed to be on the trash can and the resident was at risk of infection.
During an interview, on 1/30/26 at 11:30 a.m., Qualified Medical Assistant (QMA) 6 indicated the catheter bag should be hung on the bed rail and never on the trash can.
When you hang the bag on the dirty trash can, the resident would be at risk of developing a major infection. A current facility policy, titled Infection Prevention and Control Program, not dated and received during entrance on 1/27/26, indicated .To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .monitors compliance with infection control practices and procedures 3.1-18(b)(1)