Wellbrooke Of Kokomo
WELLBROOKE OF KOKOMO in KOKOMO, IN — inspection on February 20, 2026.
Found 5 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
Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for MDS assessments. (Resident
diagnoses included, but were not limited to, malignant neoplasm of the breast, malignant neoplasm of the ovary, and metastatic brain cancer.
The MDS assessment, dated 1/23/26, did not include cancer diagnoses.
During an interview, on 2/19/26 at 2:49 p.m., the Clinical Support Nurse indicated the MDS assessment should have included the cancer diagnoses, and a care plan should have been in place.
The facility did not have a policy for MDS accuracy.
The facility followed the Resident Assessment Instrument (RAI) manual.
During an interview, on 2/20/26 at 10:24 a.m., RN 12 indicated the cancer diagnoses were not included on the MDS assessment dated [DATE].3.1-31(c)(1) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155819 02/20/2026
Wellbrooke of Kokomo 2200 South Dixon Road Kokomo, IN 46902
actions that can be measured.
care plans were developed and implemented for 1 of 1 resident reviewed for care plans. (Resident
diagnoses included, but were not limited to, congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer.A physician's order, dated 1/18/26, indicated to administer furosemide (a diuretic medication) 40 milligrams (mg) twice a day.A physician's order, dated 1/23/26, indicated to administer quetiapine (an antipsychotic medication) 25 mg once a day for brain metastasis.A physician's order, dated 2/7/26, indicated to administer insulin lispro (a diabetic medication) according to the sliding scale before meals and at bedtime.
The clinical record did not contain a care plan related to congestive heart failure and the use of diuretic medication, type 2 diabetes mellitus and the use of diabetic medication, or metastatic brain cancer and the use of antipsychotic medication.
During an interview, on 2/19/26 at 9:58 a.m., Licensed Practical Nurse 8 indicated the resident should have had care plans in place for congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer.
During an interview, on 2/19/26 at 2:49 p.m., the Clinical Support Nurse indicated the resident should have had care plans in place for congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer.
During an interview, on 2/20/26 at 10:21 a.m., RN 12 indicated the resident should have had care plans in place for congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer.A current facility policy, titled Comprehensive Care Plan Guidelines, dated 5/22/18 and received from the Clinical Support Nurse on 2/19/26 at 2:40 p.m., indicated .to ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .A comprehensive care plan will be developed within 7 days of the admission comprehensive assessment.Comprehensive care plans need to remain accurate and current 3.1-35(a)3.1-35(b)(1)
155819 02/20/2026
Wellbrooke of Kokomo 2200 South Dixon Road Kokomo, IN 46902
after admission; after medications listed above are prescribed; and with dosage changes A current
indicated .The medication administration record (MAR) should contain supplemental information to
on MAR or the EHR. An explanatory note is also entered.3.1-37(a)
155819 02/20/2026
Wellbrooke of Kokomo 2200 South Dixon Road Kokomo, IN 46902
Based on observation, interview and record review, the facility failed to ensure controlled substance
reviewed for medication storage. (100 hall front cart)Findings include:During an observation, on 2/16/26 at 10:45 a.m., the 100-hall front medication cart had two compromised controlled substance cards.a. A card of oxycodone (a narcotic pain medication) 5 milligram tablets for Resident 2 had clear tape covering the back of the number 4 and 5 slots.Resident 2 had discharged from the facility on 2/7/26 and the controlled substance card continued to be stored in the medication cart.
During an interview, on 2/18/26 at 10:09 a.m., Qualified Medication Aide (QMA) 4 indicated when narcotic medications were discontinued the nurse and Director of Nursing (DON) would destroy the medication and not leave the medication in the cart.b. A card of Norco (a narcotic pain medication) 10/325 mg tablets for Resident 43 had a slit on the back of the card in the number 4 slot.
During an interview, on 2/16/26 at 10:55 p.m., Registered Nurse (RN) 2 indicated the substance control cards should not be taped or have slits on the back of the cards.
During an interview, on 2/16/26 at 11:07 a.m., the Director of Nursing (DON) indicated the staff should not tape the backs of the narcotics cards.
The pills needed to be destroyed, it could be considered a drug diversion, and the medication could be a different pill.A current facility policy, titled Guidelines for Disposal of Controlled Drugs, dated as reviewed on 12/10/25 and received from the Executive Director on 2/20/26 at 9:10 a.m., indicated .When disposing of pharmaceutical controlled substances by transferring those substances into a collection receptacle, such disposal shall occur immediately, but no longer than three (3) business days after discontinuation of use by the LTCF resident.
Discontinuation of use includes a permanent discontinuation of all as directed by the prescriber, as a result of the resident's transfer from the long-term care facility, or as a result of death.A current facility policy, titled Medication Storage In The Facility, dated as reviewed on 11/2018 and received from the Director of Nursing on 2/16/26 at 12:44 p.m., indicated .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal 3.1-25(o)
155819 02/20/2026
Wellbrooke of Kokomo 2200 South Dixon Road Kokomo, IN 46902
During an interview, on 2/16/26 at 11:53 a.m., the Director of Nursing (DON) indicated the resident should have had enhanced barrier precautions in place for her PICC line and should have had contact precautions in place for her diagnosis of VRE.
During an interview, on 2/19/26 at 11:33 a.m., QMA 9 indicated if a resident arrived from the hospital with a line (IV, Catheter, etc.) or a transmissible infection, the resident would be placed in enhanced barrier precautions or contact precautions, whichever was appropriate, as soon as they arrived to the facility.
A current facility policy, titled Guidelines for Contact Precautions, dated 11/28/16 and received from the Clinical Support Nurse on 2/16/26 at 2:16 p.m., indicated .Contact precautions are indicated to prevent and control HAI (health-care associated infections) transmission of infection with any of the following: a.
Vancomycin resistant enterococcus species. (VRE ).Precaution Sign: a.
Post a sign at the resident's door that is appropriate according to CDC guidance.
A current facility policy, titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 4/1/24 and received from the Clinical Support Nurse on 2/16/26 at 12:56 p.m., indicated .Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions.All Residents with indwelling medical devices 1.
Includes but not limited to: catheters, central lines.Personal Protective Equipment (PPE) should be used.at minimum, staff shall wear gloves and gowns during high-contact care activities.
A current policy, titled Enhanced Barrier Precaution, dated 6/24 and provided by the Assistant Director of Nursing (ADON) on 12/6/24 at 3:00 p.m., indicated .Enhanced Barrier Precautions All residents with any of the following: Wounds .feeding tube, regardless of MDRO colonization status .Required PPE .Gloves and gown prior to the high contact care activity 3.1-18(b)(1) 3.1-18(b)(2)