Inspection Report Summary
The most recent inspection on April 15, 2025, cited a deficiency for failing to provide annual health statements showing no evidence of infectious tuberculosis for several residents. Earlier inspections showed a mix of compliance and deficiencies, including issues with fire and disaster drill documentation and medication labeling, as well as substantiated complaints involving resident neglect and misappropriation of property. The main themes of deficiencies involved documentation and resident safety, including medication management and supervision of residents at risk. Several complaint investigations were substantiated, with one involving neglect that led to a resident’s fall and injury, and another involving theft by a staff member; enforcement actions included staff termination and police involvement. The facility’s inspection history shows some ongoing challenges with compliance, although corrective actions have been implemented following cited deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
55 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 55
Deficiencies: 1
Apr 15, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 15 and 16, 2025, to assess compliance with state residential regulations.
Findings
The facility failed to ensure that annual health statements showing no evidence of tuberculosis in an infectious stage were provided for 5 of 7 residents reviewed. The deficiency involved residents 21, 66, 54, 82, and 83, with some residents deceased. The facility has implemented corrective actions including updating health statements, re-educating staff, and auditing resident records to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Failed to ensure an annual health statement was provided showing no evidence of tuberculosis in an infectious stage for 5 of 7 residents reviewed. |
Report Facts
Residential Census: 55
Residents reviewed for annual health statements: 7
Residents lacking current annual health statement: 5
Audit frequency: 5
Acceptable compliance threshold: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nanette Albright | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding resident information and compliance with annual health statements |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 2
May 21, 2024
Visit Reason
This survey was conducted as a State Residential Licensure Survey including the investigation of Complaint IN00434187.
Findings
No deficiencies related to the complaint allegations were cited. However, deficiencies were found related to failure to conduct fire and disaster drills in conjunction with the local fire department at least every six months and failure to conduct quarterly fire drills on each shift. Additionally, deficiencies were found related to improper labeling of medications after order changes for 2 of 5 residents observed during medication administration.
Complaint Details
Complaint IN00434187 was investigated with no deficiencies related to the allegations cited.
Deficiencies (2)
| Description |
|---|
| Facility failed to show documentation of fire and disaster drills conducted in conjunction with the local fire department at least once every six months and failed to show documentation that fire drills were conducted quarterly on each shift. |
| Facility failed to properly label medications after an order change for 2 of 5 residents observed during medication administration. |
Report Facts
Fire drills completed on first shift: 6
Fire drills completed on second shift: 4
Fire drills completed on third shift: 2
Residents present: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nanette Albright | Executive Director | Signed the report and was interviewed regarding fire and disaster drills. |
| LPN 1 | Observed administering medications and noted labeling deficiencies. | |
| Maintenance Director | Interviewed regarding fire and disaster drills not conducted with local fire department. | |
| Director of Nursing | Interviewed regarding medication order clarifications and fire drill schedules. |
Inspection Report
Census: 72
Deficiencies: 0
May 24, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on May 23 and 24, 2023.
Findings
Primrose Retirement Community of Kokomo was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Nov 28, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00389913 and IN00391844 at Primrose Retirement Community of Kokomo.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00389913 - Substantiated with no deficiencies cited. Complaint IN00391844 - Substantiated with no deficiencies cited.
Report Facts
Facility number: 11555
Inspection Report
Follow-Up
Census: 65
Deficiencies: 0
Oct 5, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00381855 completed on July 27, 2022, and was conducted in conjunction with the PSR to the Investigation of Complaint IN00386391 completed on August 12, 2022.
Findings
Primrose Retirement Community of Kokomo was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the Investigation of Complaint IN00381855. Both complaints IN00381855 and IN00386391 were corrected.
Complaint Details
This visit was related to complaints IN00381855 and IN00386391, both of which were corrected.
Report Facts
Residential Census: 65
Inspection Report
Follow-Up
Census: 65
Deficiencies: 0
Oct 5, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00386391 completed on August 12, 2022, and was conducted in conjunction with the PSR to the Investigation of Complaint IN00381855 completed on July 27, 2022.
Findings
Primrose Retirement Community of Kokomo was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the Investigation of Complaint IN00386391. Both complaints IN00386391 and IN00381855 were corrected.
Complaint Details
This visit was related to complaints IN00386391 and IN00381855, both of which were corrected.
Report Facts
Residential Census: 65
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Aug 11, 2022
Visit Reason
This survey was conducted for the investigation of Complaint IN00386391, which was substantiated with related state deficiencies cited.
Findings
The facility failed to ensure a resident's checkbook was kept safe and secure during her admission, resulting in misappropriation of property. A maintenance assistant forged the resident's signature on a check and cashed it, leading to his termination and police involvement.
Complaint Details
Complaint IN00386391 was substantiated. The investigation revealed that Maintenance Assistant 5 forged Resident B's signature on a check and cashed it. The resident left her apartment doors unlocked and kept valuables in plain sight. The maintenance assistant was terminated and charged with forgery. The bank teller who cashed the check violated bank policy by not verifying the check with the resident.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a resident's checkbook was kept safe and secure during admission, leading to misappropriation of property. |
Report Facts
Resident census: 71
Loss amount: 125
Dates of survey: 2022-08-11 to 2022-08-12
Employment dates: Maintenance Assistant 5 was hired on 2022-07-08 and terminated on 2022-07-26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Assistant 5 | Maintenance Assistant | Named in the finding for forging and cashing a resident's check, terminated after investigation |
| Executive Director | Executive Director | Interviewed during investigation and responsible for reporting and corrective actions |
| Police Officer 2 | Police Officer | Responded to the facility, escorted Maintenance Assistant 5 out, and involved in investigation |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Jul 27, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00381855, which was substantiated with state deficiencies related to the allegations cited.
Findings
The facility failed to ensure a resident (Resident B) was free from neglect when she was left unattended on the toilet by a CNA, resulting in a fall and fractured nose. The resident had vascular dementia and was identified as high risk for falls. The CNA was new and did not follow the resident's care plan requiring two-person assistance.
Complaint Details
Complaint IN00381855 was substantiated. The investigation found that Resident B, diagnosed with vascular dementia and high fall risk, was left unattended by CNA 1 who went to get clothes, leading to a fall and injury.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a resident was free from neglect related to being left unattended on the toilet, resulting in a fall and fractured nose. |
Report Facts
Survey dates: July 26 and 27, 2022
Resident census: 71
Fall incident date and time: 3/3/22 at 3:20 p.m.
Mini Mental Status Exam score: 18
Completion date for corrective action: August 31, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in neglect finding for leaving Resident B unattended leading to fall |
| Director of Nursing Services | DNS | Provided interviews and signed documents related to Resident B's care and fall investigation |
| Executive Director | ED | Provided fall investigation report and interviews |
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