Wellbrooke of Kokomo

In the surveyor’s words

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

• Actual harm, isolatedF684Feb 14, 2024

  Based on record review and interview, the facility failed to ensure significant weight changes were identified and timely interventions were implemented for 2 of 5 residents reviewed for changes in weight (Resident 109 and 19). This deficient practice resulted in Resident 109 experiencing two events of significant weight gain which required hospitalization for fluid overload and Resident 19 experiencing significant weight loss which required hospitalization for altered mental status and dehydration. Finding includes: 1. The clinical record for Resident 109 was reviewed on 2/12/24 at 4:19 p.m. […]

• Actual harm, isolatedF760Mar 8, 2023

  Based on interview and record review, the facility failed to ensure a resident received medications according to the hospital discharge instructions for 1 of 3 residents reviewed for significant medication error. (Resident B) Resident B was readmitted to the hospital. Findings include: The record for Resident B was reviewed on 3/7/2023 at 2:46 p.m. Diagnoses included, but were not limited to, saddle embolus of pulmonary artery with acute cor pulmonale, acute respiratory failure with hypoxia, acute embolism, and thrombosis of unspecified deep veins of lower extremity, bilateral, hypotension, and type 2 diabetes mellitus with hyperglycemia. […]

• No harm, potential for more than minimal, patternF623Mar 18, 2025

  4. The clinical record for Resident 18 was reviewed on 3/12/25 at 12:07 a.m. The diagnoses included, but were not limited to, acute respiratory failure, hypertension, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and diabetes mellitus. A nursing progress note, dated 1/12/25 at 11:49 a.m., indicated the resident was transferred to the hospital for a decline in condition and increased confusion. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital. 5. The clinical record for Resident 74 was reviewed on 3/14/25 at 11:11 a.m. […]

• No harm, potential for more than minimal, patternF625Mar 18, 2025

  3. The clinical record for Resident 30 was reviewed on 3/17/25 at 10:02 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, pulmonary embolism, hypertension, congestive heart failure, obesity, cerebrovascular accident, hemiplegia, hemiparesis, transient ischemic attack, and muscle weakness. A nursing progress note, dated 1/18/25 at 12:25 p.m., indicated the resident was sent to the emergency room for evaluation. A nursing progress note, dated 1/19/25 at 4:08 a.m., indicated the resident had been admitted to the hospital for pulmonary embolism and right heart strain. […]

• No harm, potential for more than minimal, patternF580Dec 7, 2022

  Based on interview and record review, the facility failed to notify the physician of significant weight changes, for not administering a long-acting insulin, and for low blood sugar readings for 7 of 7 residents reviewed for notification. (Residents L, T, S, C, M, K and Q) Findings include: 1. The record for Resident L was reviewed on 12/5/22 at 2:50 p.m. Diagnoses included, but were not limited to, altered mental status, type 2 diabetes mellitus, hearing loss, and generalized muscle weakness. A physician's order, dated 5/23/22, indicated CCHO (consistent carbohydrate) mechanical soft diet with thin liquids. A physician's order, dated 11/21/22, indicated a weekly weight on Mondays. The resident had the following weights: a. On 4/19/22, the weight was 154.4 pounds. b. […]