Kokomo Healthcare Center

In the surveyor’s words

From the most serious findings on record at Kokomo Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Sep 21, 2022

  Based on interview and record review, the facility failed to ensure staff assessed and notified the physician of a resident who experienced a change in condition timely and failed to initiate cardiopulmonary resuscitation (CPR) when a resident went unresponsive for 1 of 3 residents reviewed for death. (Resident B) The immediate jeopardy began on [DATE], when Resident B had a change of condition which was not assessed by the licensed nurse on duty. Resident B was later found unresponsive, and the licensed nurse failed to start CPR and notify the physician of the death. The Executive Director (ED) and Regional Nurse Consultant (RNC) were notified of the immediate jeopardy on [DATE] at 2:20 p.m. […]

• Immediate jeopardy, isolatedF600Oct 7, 2021

  Based on interview and record review, the facility failed to ensure a resident was free from physical abuse when a resident with known aggressive behaviors (Resident B) had a verbal and physical altercation with another resident (Resident C) for 2 of 3 residents reviewed for abuse. Resident C had to be evaluated in the emergency room (ER) after the physical altercation. The Immediate Jeopardy began on September 18, 2021 when Resident B verbally and physically attacked Resident C. Resident C was assessed and noted with right eye swelling, petechiae (a small red or purple spot caused by bleeding into the skin) by the hairline and an abrasion to the right elbow and the left ankle. The resident complained of pain and double vision. Resident C indicated she feared for her life. […]

• Immediate jeopardy, isolatedF600Sep 3, 2021

  Based on interview and record review, the facility failed to ensure a resident with a mild intellectual disability and an impulse disorder was free from abuse when the resident and a staff member had a verbal and physical altercation for 1 of 3 residents reviewed for abuse (Resident B and LPN 1). The immediate jeopardy began on August 17, 2021, when Resident B and LPN 1 had a verbal and physical altercation. LPN 1 continued to follow, instigate, and taunt the resident after the resident attempted to remove himself from the situation on two separate occasions. The Executive Director (ED), Director of Nurses (DON) and Regional Director of Clinical Services (RDOC) were notified of the immediate jeopardy at 4:42 p.m., on 9/02/21. […]

• Actual harm, isolatedF689Apr 5, 2022

  Based on observation, interview and record review, the facility failed to provide adequate supervision for a resident who required assistance of two staff with activities of daily living (ADL's) for 1 of 1 resident reviewed for accidents. (Resident 6) Resident 6 while receiving care from one CNA, fell from the bed and sustained significant injury requiring transport to the emergency room . Finding includes: During an interview, on 04/01/2022 at 10:03 a.m., Resident 6 was observed to be in bed with an oversized mattress. The bed was in the high position, with the top of the mattress to the floor estimated to have been 3 1/2 feet. The resident had an above the knee amputation to the left lower extremity and limited use of his left arm and hand. […]

• Actual harm, isolatedF692Dec 14, 2021

  Based on interview and record review, the facility failed to identify a significant weight loss, notify the physician of the weight loss and implement interventions to prevent further weight loss for 1 of 3 residents reviewed for nutrition (Resident D). Resident D had a 12.73% weight loss in less than 80 days. Finding includes: During an interview, while on the initial tour starting at 11:21 a.m. on 12/13/21, Resident D indicated he just didn't have an appetite although the food was not bad. The record for Resident D was reviewed on 12/13/21 at 2:47 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 9/13/21, indicated a regular diet, regular texture and regular consistency. […]