Inspection Reports for
Waterford Place Health Campus
800 St Joseph Dr, Kokomo, IN 46901, KOKOMO, IN, 46901
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
210% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
71% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Census: 73
Capacity: 103
Deficiencies: 0
Date: May 15, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas.
Inspection Report
Complaint Investigation
Census: 74
Capacity: 116
Deficiencies: 0
Date: Mar 31, 2025
Visit Reason
This visit was conducted to investigate Complaint IN00455832 at Waterford Place Health Campus.
Complaint Details
Complaint IN00455832 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type Total: 116
Census Payor Type Total: 74
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure survey and the Investigation of Complaint IN00450780.
Complaint Details
Investigation of Complaint IN00450780 was completed on February 17, 2025. The facility was found in compliance.
Findings
Waterford Place Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey and the Investigation of Complaint IN00450780.
Inspection Report
Life Safety
Census: 73
Capacity: 103
Deficiencies: 11
Date: Mar 17, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including building construction type maintenance, dead-end corridors, illumination of means of egress, emergency lighting, fire alarm system maintenance, portable fire extinguisher installation, corridor door compliance, fire drill documentation, electrical system labeling and maintenance, and emergency generator remote stop installation.
Deficiencies (11)
K161 - Building Construction Type and Height: The facility failed to maintain the building construction type due to a 90-minute fire door that failed to self-close and latch, compromising the two-hour fire barrier wall near the Main Dining Room.
K251 - Dead end Corridors and common Path of Travel: One of seven exit access corridors had a dead-end exceeding 30 feet due to conversion of resident rooms to a dialysis center, affecting two resident rooms.
K281 - Illumination of Means of Egress: The exit discharge for the 600 Hall by Room 617 was not arranged to prevent illumination failure if a single lighting fixture failed, as one fixture had only one bulb installed.
K291 - Emergency Lighting: One of six battery powered emergency lighting systems failed to illuminate during testing above the emergency generator transfer switches in the main electrical room.
K345 - Fire Alarm System – Testing & Maintenance: The fire alarm control panel was in trouble mode and silenced due to a duct detector needing repair, which was not corrected at the time of survey.
K355 - Fire Extinguishers: One of 19 portable fire extinguishers was improperly installed, being freestanding on top of a water softener storage bin instead of mounted securely on the wall.
K363 - Corridor - Doors: One corridor door to resident sleeping Room 308 was propped open with a wedge, preventing it from closing and latching properly to resist smoke passage.
K712 - Fire Drills: The facility failed to document a quarterly fire drill on the third shift for the fourth quarter of 2024.
K911 - Electrical System-Other: Two electrical panels had most overcurrent devices not identified, including the 'A.D. Critical' panel and the 'SEM' panel, complicating circuit identification.
K914 - Electrical Systems-Maintenance and Testing: Documentation of electrical outlet receptacle testing for all resident sleeping rooms was incomplete, lacking itemization by receptacle location and ground retention test results.
K918 - Electrical Systems-Essential Electric Style: The emergency generator lacked a properly located and labeled remote manual stop station outside the generator housing.
Report Facts
Facility Capacity: 103
Resident Census: 73
Number of portable fire extinguishers: 19
Number of exit access corridors: 7
Number of battery powered emergency lighting systems: 6
Number of electrical panels: 10
Inspection Report
Annual Inspection
Census: 126
Deficiencies: 5
Date: Feb 17, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of complaints IN00449458 and IN00450780.
Complaint Details
Complaint IN00449458 had no deficiencies related to the allegations. Complaint IN00450780 had federal/state deficiencies cited at F921 related to environmental sanitation issues.
Findings
The facility was found deficient in multiple areas including failure to follow physician medication orders, failure to notify hospice of elevated blood glucose readings, improper oxygen administration without physician orders, and unsanitary environmental conditions in resident rooms and hallways. Additionally, personnel records lacked job-specific orientation and annual in-service training documentation for some staff.
Deficiencies (5)
F684 - Quality of Care: The facility failed to follow physician orders for medication hold parameters, notify hospice of elevated blood glucose readings, and obtain ordered blood glucose readings for 3 residents.
F695 - Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure oxygen was administered at the physician's ordered level and failed to obtain physician orders for oxygen administration for 4 residents.
F921 - Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain clean and sanitary resident rooms and hallways, including strong odors, peeling paint, unsecured electrical outlets, dried blood on walls and bedding, and presence of bugs.
R119 - Personnel – Noncompliance: The facility failed to ensure job specific orientation was completed and maintained in employee records for 2 staff members.
R120 - Personnel - Noncompliance: The facility failed to ensure annual in-service education was completed for 2 staff members.
Report Facts
Census Bed Type Total: 126
Census Payor Type Total: 84
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Missing job specific orientation documentation | |
| RN 4 | Missing job specific orientation documentation | |
| CNA 1 | Missing annual in-service training documentation | |
| LPN 2 | Missing annual in-service training documentation |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
This visit was for the investigation of complaints IN00438850 and IN00439833.
Complaint Details
Investigation of Complaints IN00438850 and IN00439833 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00438850 and IN00439833 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 120
Census Payor Type Total: 78
Census Bed Type SNF: 36
Census Bed Type SNF/NF: 42
Census Bed Type Residential: 42
Census Payor Type Medicare: 25
Census Payor Type Medicaid: 37
Census Payor Type Other: 16
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Date: May 14, 2024
Visit Reason
This visit was conducted to investigate Complaint IN00433702 at Waterford Place Health Campus.
Complaint Details
Complaint IN00433702 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census Bed Type Total: 117
Census Payor Type Total: 77
SNF Census: 33
SNF/NF Census: 44
Residential Census: 40
Medicare Census: 27
Medicaid Census: 39
Other Payor Census: 11
Inspection Report
Life Safety
Census: 60
Capacity: 103
Deficiencies: 0
Date: Mar 6, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with 42 CFR Subpart 483.90(a).
Findings
The facility was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility is a one-story, fully sprinklered building with a fire alarm system and smoke detection in corridors and resident rooms.
Inspection Report
Life Safety
Census: 80
Capacity: 103
Deficiencies: 8
Date: Jan 29, 2024
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies related to fire barrier penetrations, egress door signage, hazardous area door self-closing, kitchen fire suppression inspection, sprinkler system maintenance, portable fire extinguisher inspections, and corridor door hold-open devices.
Deficiencies (8)
K131 Multiple Occupancies: The facility failed to ensure a penetration in a fire barrier wall was sealed to maintain fire resistance. Maintenance sealed the hole during the survey.
K222 Egress Doors: One delayed egress lock lacked proper signage indicating the door can be opened in 15 seconds. Signage was installed during the survey.
K321 Hazardous Areas - Enclosure: The door to a hazardous storage room did not latch properly despite having a self-closing device. Maintenance repaired the door during the survey.
K324 Cooking Facilities: The kitchen fire suppression system was not inspected semiannually as required. Documentation for one inspection was missing.
K351 Sprinkler System - Installation: The facility failed to maintain ceiling construction around sprinkler heads; a missing escutcheon was replaced during the survey.
K353 Sprinkler System - Maintenance and Testing: The facility lacked documentation for sprinkler system inspections for 2 of 4 quarters in 2023.
K355 Fire Extinguishers: Two portable fire extinguishers lacked documentation of monthly inspections for November and December 2023. Documentation was corrected during the survey.
K363 Corridor-Doors: A door was held open with a wedge preventing it from closing properly. The wedge was removed during the survey.
Report Facts
Facility Capacity: 103
Census: 80
Residents potentially affected: 10
Residents potentially affected: 5
Residents potentially affected: 5
Residents potentially affected: 20
Residents potentially affected: 5
Residents potentially affected: 10
Residents potentially affected: 6
Inspection Report
Recertification
Census: 71
Capacity: 112
Deficiencies: 5
Date: Jan 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and an Investigation of Complaint IN00423969.
Complaint Details
Complaint IN00432969 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found to have deficiencies related to Medicaid/Medicare coverage notices, activities for isolated residents, quality of care regarding blood sugar monitoring, nutrition/hydration status maintenance, and medication storage. No deficiencies were cited related to the complaint investigation.
Deficiencies (5)
F582 – The facility failed to ensure documentation showed residents or representatives made choices about Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage for 2 of 3 residents reviewed.
F679 – The facility failed to provide preferred activities to a cognitively impaired resident in isolation for Covid-19, with no documentation of activities provided.
F684 – The facility failed to follow physician's orders to call the provider and complete re-checks for low blood sugars for 1 resident reviewed for quality of care related to insulin.
F692 – The facility failed to identify weight loss, notify the physician, and implement interventions for 1 resident reviewed for nutrition.
R298 – The facility failed to ensure narcotic medications were stored in tamper-free containers and food was not stored in the medication refrigerator.
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 45
Census Bed Type - SNF: 26
Census Bed Type - Residential: 41
Total Census: 112
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 16
Total Census Payor: 71
Weight loss percentage: 6.64
Blood sugar low readings without re-check or call: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Bishir | Executive Director | Signed the report. |
| Social Services Director | Interviewed regarding SNF ABN form deficiencies and lack of policy. | |
| Director of Assisted Living | Interviewed regarding medication storage and food in medication refrigerator. | |
| Director of Health Services | Interviewed regarding blood sugar monitoring deficiencies and medication storage. | |
| Legacy Unit Manager | Interviewed regarding resident's television remote and activity participation. | |
| Life Enrichment Staff 4 | Interviewed regarding resident activity documentation. | |
| Life Enrichment Clinical Support | Provided policies and interviewed regarding activity program and documentation. | |
| Clinical Support Nurse | Provided policies and interviewed regarding medication storage and weight loss monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on January 9, 2024.
Findings
Waterford Place Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the Recertification and State Licensure survey.
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00420503 completed on November 20, 2023.
Complaint Details
Investigation of Complaint IN00420503 was completed and corrected.
Findings
Waterford Place Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00420503.
Inspection Report
Complaint Investigation
Census: 43
Capacity: 114
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00420389 and Residential Complaint IN00420503.
Complaint Details
Complaint IN00420389 was not substantiated with deficiencies. Complaint IN00420503 was substantiated with state deficiencies related to medication administration errors resulting in Resident B's overdose and hospitalization.
Findings
No deficiencies were cited related to Complaint IN00420389. State deficiencies related to Complaint IN00420503 were cited concerning a medication administration error involving Resident B, who received an incorrect dose of an anti-anxiety medication resulting in hospitalization for overdose.
Deficiencies (1)
410 IAC 16.2-5-4(e)(1) Health Services - Offense: The facility failed to ensure the Nurse Practitioner entered a medication order correctly and a Qualified Medication Aide notified a licensed nurse regarding the medication order discrepancy to prevent a medication error for Resident B.
Report Facts
Resident census: 43
Total licensed capacity: 114
Medication tablets administered: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Bishir | Executive Director | Signed the inspection report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 143
Deficiencies: 0
Date: Aug 8, 2023
Visit Reason
This visit was for the investigation of Complaint IN00413715 at Waterford Place Health Campus.
Complaint Details
Complaint IN00413715 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00413715 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type Total: 143
Census Payor Type Total: 79
SNF Census: 33
SNF/NF Census: 46
Residential Census: 64
Medicare Census: 25
Medicaid Census: 39
Other Payor Census: 15
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Date: Apr 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00401175.
Complaint Details
Complaint IN00401175 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 125
Census Payor Type Total: 67
Census Bed Type SNF: 24
Census Bed Type SNF/NF: 43
Census Bed Type Residential: 58
Census Payor Type Medicare: 18
Census Payor Type Medicaid: 34
Census Payor Type Other: 15
Inspection Report
Re-Inspection
Census: 134
Deficiencies: 0
Date: Jan 31, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and to the Investigation of Nursing Home and Residential Complaints completed on November 21, 2022.
Complaint Details
Complaint IN00388949 and Complaint IN00391896 were investigated and found to be corrected.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the Investigation of Complaint IN00388949. Both complaints investigated were corrected.
Report Facts
Census Bed Type Total: 134
Census Payor Type Total: 70
SNF/NF Beds: 44
SNF Beds: 26
Residential Beds: 64
Medicare Residents: 26
Medicaid Residents: 35
Other Payor Residents: 9
Inspection Report
Re-Inspection
Census: 72
Capacity: 103
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with the Life Safety Code and state licensure requirements.
Findings
The facility was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a). No deficiencies were cited during this Life Safety Code Survey.
Inspection Report
Life Safety
Census: 61
Capacity: 103
Deficiencies: 5
Date: Dec 29, 2022
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including delayed egress locking arrangements, hazardous area enclosures, fire alarm system maintenance, fire drills, and improper use of extension cords. Immediate interventions and corrective actions were planned or implemented.
Deficiencies (5)
K-222 – Egress Doors: The facility failed to ensure the delayed egress locking arrangement released the lock within the required time upon application of force on the exit door in the Transitional Care area. This affected 30 residents.
K-321 – Hazardous Areas – Enclosure: The facility failed to ensure two corridor doors to the laundry room did not latch properly and one consultation room with combustible storage was not protected as a hazardous area. This affected staff and 6 residents.
K-345 – NFPA 101 Fire Alarm System – Testing and Maintenance: The fire alarm control panel was in trouble mode due to a water leak and was not properly maintained, affecting all residents and staff.
K-712 – Fire Drills: The facility failed to conduct fire drills on each shift for 5 of 12 required drills, affecting all staff and residents.
K-920 – Electrical Equipment - Power Cords and Extension Cords: An extension cord was used as a substitute for fixed wiring in resident room 607, which is not permitted. This affected 2 residents.
Report Facts
Residents affected: 30
Residents affected: 6
Residents affected: 2
Fire drills missing: 5
Inspection Report
Recertification
Census: 73
Capacity: 138
Deficiencies: 17
Date: Nov 21, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey. This visit also included the Investigation of Nursing Home Complaint IN00388949 and Residential Complaint IN00391896.
Complaint Details
Complaint IN00388949 - Substantiated. Federal/State deficiencies related to the allegations are cited at F561. Complaint IN00391896 - Substantiated. State deficiencies related to the allegations are cited at R217.
Findings
The facility was found to have deficiencies related to resident self-determination, notification of changes, comprehensive assessments, PASARR coordination, professional standards for psychotropic medication use, quality of care including medication side effects and pressure ulcer care, accident hazards including falls and bed rails, tube feeding management, respiratory care, medication storage, food preferences, food safety, and administration and management including fire drills and service plans.
Deficiencies (17)
F561 Self Determination: The facility failed to assess a resident for the preferred time to get out of bed for 1 of 2 residents reviewed for choices.
F580 Notify of Changes: The facility failed to ensure the physician was notified of a significant weight gain for 2 of 2 residents reviewed for notification.
F637 Comprehensive Assessment After Significant Change: The facility failed to complete a comprehensive care plan to reflect a significant change for 1 of 1 resident reviewed for hospice services.
F644 Coordination of PASARR and Assessments: The facility failed to ensure a new PASARR was completed when an antipsychotic medication and new mental health diagnosis was added for 3 of 3 residents reviewed for PASARR.
F658 Services Provided Meet Professional Standards: The facility failed to ensure a resident who was diagnosed with dementia met the criteria for a new diagnosis of schizophrenia for 1 of 6 residents reviewed for professional standards of quality.
F684 Quality of Care: The facility failed to assess and document abnormal mouth movements for 1 of 3 residents reviewed for potential medication side effects.
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: The facility failed to ensure a resident at risk for pressure ulcers received necessary care, treatment, and services consistent with professional standards to prevent and promote healing for 1 of 1 resident reviewed.
F689 Free of Accidents/Hazards/Supervision/Devices: The facility failed to identify unique characteristics and abilities, provide supervision, monitor effectiveness of interventions, and modify the care plan with fall prevention interventions for 1 of 1 resident reviewed for falls.
F693 Tube Feeding Mgmt/Restore Eating Skills: The facility failed to ensure residents with gastrostomy tube feeding received care and services for the feeding tube to meet the resident's needs related to residual volume checks and proper storage of feeding equipment for 2 of 2 residents reviewed.
F694 Parenteral/IV Fluids: The facility failed to provide PICC care including dressing changes, flushing, monitoring, and tubing changes for 1 of 2 residents reviewed for PICC line care.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure oxygen nasal cannula and nebulizer equipment were dated and labeled, failed to ensure physician's order was followed, and failed to ensure BiPAP settings were ordered for 4 of 4 residents reviewed for respiratory care.
F700 Bed Rails: The facility failed to obtain a physician's order, develop a care plan, obtain consent, ensure bed rails were installed correctly, and perform scheduled maintenance for the use of side rails for 2 of 2 residents reviewed.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure drugs and biologicals were stored in accordance with professional standards for 2 of 2 residents and failed to dispose of loose pills in 4 of 7 medication carts reviewed.
F806 Resident Allergies, Preferences, Substitutes: The facility failed to ensure a resident's food preferences were accommodated for 1 of 1 resident reviewed for food preferences.
R090 Administration and Management - Deficiency: The facility failed to post the most recent survey results or a notice to indicate where the survey results could be located in 1 of 2 buildings reviewed.
R092 Administration and Management - Noncompliance: The facility failed to conduct a quarterly fire drill on each shift for the period of the last quarter of 2021 through the last quarter of 2022.
R217 Evaluation - Deficiency: The facility failed to ensure service plans were signed and dated by the resident or resident's representative for 7 of 7 residents reviewed for service plans.
Report Facts
Census Payor Type: 73
Census Bed Type: 138
Deficiencies cited: 16
Falls: 134
Weight gain: 12.58
Weight gain: 10.39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Bishir | Executive Director | Signed report on 12/12/2022 |
| Nurse 6 | Registered Nurse | Named in medication administration and resident preference findings |
| Clinical Support Nurse | Provided policies and interviewed about deficiencies | |
| Director of Nursing | Interviewed about resident weight gain and medication storage | |
| Social Service Director | Interviewed about PASARR and psychotropic medication use | |
| Certified Resident Medication Aide | Interviewed about medication cart loose pills | |
| Dietary Manager | Interviewed about food preferences and hair restraint | |
| Director of Plant Operations | Interviewed about fire drill posting and bed rail maintenance | |
| Corporate Nurse Support | Interviewed about PICC line care and medication storage | |
| Registered Nurse 2 | Observed leaving IV bag unsecured on medication cart |
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