Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Kokomo during CMS and state inspections, most recent first.
A resident with multiple risk factors for skin breakdown, including Parkinson’s disease, incontinence, and impaired mobility, developed a facility-acquired Stage III pressure ulcer on the coccyx after a lapse in documented preventive hydrocolloid dressings. The resident had complained of soreness before staff discovered the open area during care, and although staff later reported the wound to the wound nurse, there was no clinical documentation on the day it was first found describing who discovered it, when it was found, or its measurements and characteristics. A subsequent wound summary documented a Stage III pressure ulcer caused by pressure, while facility policy required immediate wound assessment, detailed documentation, and measurement when skin breakdown is identified, leading to the cited deficiency.
A resident with paraplegia was admitted to a facility with a loaner wheelchair, which was lost after admission. Despite being transported in the wheelchair, it was not documented, and staff were unaware of its location. The facility failed to uphold the resident's right to retain personal possessions, resulting in a deficiency citation.
A facility failed to accurately assess and document a resident's pressure ulcer upon admission, leading to a deterioration from an almost healed state to a Stage 4 ulcer. The initial and subsequent assessments lacked comprehensive details such as size, stage, and drainage, contrary to the facility's policy. The resident had a history of paraplegia and muscle atrophy, and the responsible ADON had left the facility around the time of admission.
A resident with a history of neurogenic bladder and paraplegia experienced trauma due to improper catheter placement by facility staff. Two nurses inserted oversized catheters incorrectly, causing bleeding and hematuria. Hospital evaluation confirmed the catheter was malpositioned, with the balloon inflated within the penile urethra. Facility documentation failed to note urine return, a critical step in proper catheter placement.
A resident was unable to access personal funds due to errors in fund management and lack of a dedicated business office manager. The resident's check was misallocated, and complications arose after discharge and readmission, delaying access to funds.
A resident with a complex medical history was not provided with the care plan interventions of 1:1 supervision and a mattress for safety, as the care plan was not updated after their return from a psychiatric facility. The DON confirmed the care plan was outdated, contrary to the facility's policy requiring regular reviews and revisions.
The facility failed to administer oxygen at the correct flow rate for two residents. One resident with COPD and other conditions was observed receiving 2 LPM instead of the ordered 3 LPM. Another resident with acute respiratory failure and other diagnoses was observed receiving oxygen at 4 LPM and between 3 and 3.5 LPM, contrary to the physician's order of 3 LPM. Staff confirmed the discrepancies, and the facility's policy requires physician verification for any changes in oxygen orders.
The facility failed to maintain RN coverage for at least 8 consecutive hours daily on several occasions during the third quarter of 2024. The DON confirmed that an RN was on call but not present in the building on specific days, and the facility lacked a staffing policy despite following state guidelines.
A resident with an overactive bladder missed several doses of Oxybutynin due to medication unavailability, resulting in increased incontinence. The facility failed to follow its policy of documenting unavailable medications and contacting the pharmacy, leading to a seven-day lapse in medication administration.
A facility failed to properly label and store medications, as observed in a medication cart where two bottles of eye drops for a resident were found opened without open dates, and six loose, unidentified pills were present. A QMA confirmed the eye drops should have been dated and loose medications removed. The facility's policy requires certain medications to have a shorter expiration date once opened.
The facility failed to serve food at proper temperatures and did not adhere to puree recipes, affecting nutritional adequacy. A resident reported receiving cold meals and unrequested menu substitutions. Observations confirmed improper food temperatures and incorrect puree preparation by two cooks, as noted by the Dietary Manager.
The facility failed to ensure residents were treated with respect and dignity by an LPN, who dismissed a resident's request for pain medication, used profanity towards another resident, and yelled at two residents for being in restricted areas. These actions violated the facility's policies on resident rights and employee conduct.
The facility failed to protect residents from theft, as evidenced by a staff member not returning change after purchasing food and drinks for two residents. One resident gave the CNA fifty dollars for food, but the CNA did not return the change. Another resident gave the CNA four dollars for a candy bar and drink, but the CNA did not return the sixty-five cents in change. The CNA was terminated for violating company policy.
Failure to Prevent and Timely Assess a Facility-Acquired Stage III Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development of a pressure ulcer and to complete a timely wound assessment for a resident who was admitted without pressure ulcers. The resident had multiple diagnoses including Parkinson’s disease, history of falls, incontinence, gait and mobility abnormalities, muscle weakness, and diarrhea. The ETAR for November showed that a hydrocolloid dressing was used on the coccyx as a preventive measure from the 1st to the 15th, but there was no physician order or documentation of any preventive dressing from the 15th through the 26th. On the 27th, a hydrocolloid dressing was documented as being applied to the tailbone after cleansing a wound, indicating that an open area had already developed. The resident reported that staff discovered the sore on the coccyx during bathing, after he had complained of soreness in that area. A nursing progress note on the 28th documented that the resident refused to get out of bed and resisted turning and repositioning, despite being educated on the importance of offloading pressure. A facility pressure injury document dated the 28th at 4:00 p.m. indicated staff had reported a new area on the coccyx to the wound nurse, and that the resident was unaware of the area. This document also stated that the wound was found on the night of the 26th at 10:30 p.m., but there was no clinical record entry on the 27th describing who found the wound, the time it was found, its measurements, or wound characteristics. A wound summary dated the 28th at 4:38 p.m. documented that the resident had a facility-acquired Stage III pressure ulcer on the coccyx, with specific measurements and tissue description, and identified pressure as the cause. Subsequent hospital and wound physician documentation described the same coccyx/sacral wound as an unstageable pressure injury at one point and later as a Stage III ulcer with changing measurements and tissue composition. The facility’s skin assessment policy required that when pressure or other skin conditions are identified, a wound assessment be initiated and documented in the chart, with the initial observation described in nursing progress notes and measurements obtained using appropriate tools. The lack of timely documentation and assessment on the date the wound was first identified, combined with the gap in documented preventive measures, led to the cited deficiency for failure to ensure a resident without a pressure ulcer did not develop one and that a wound assessment was completed when the wound was discovered.
Loss of Resident's Specialized Wheelchair
Penalty
Summary
The facility failed to ensure the respect and retention of a resident's personal property, specifically a specialized wheelchair, after the resident's discharge. Resident B, who had medical conditions including flaccid neuropathic bladder, complete paraplegia, and muscle wasting and atrophy, was admitted to the facility with a loaner Quickie QRI blue wheelchair from a specialized company. Upon admission, the resident was transported in the wheelchair, but it was not documented in the admission records. The Executive Director and other staff members were unaware of the wheelchair's whereabouts after the resident was placed in bed, and the wheelchair was never seen again. Interviews with various staff members and external parties confirmed that the resident was transported to the facility in the loaner wheelchair, which was intended for use until a custom wheelchair was made. Despite efforts to locate the wheelchair, including a request for a description from the resident's mother, the facility was unable to find it. The facility's policy on resident rights, which includes the right to retain and use personal possessions, was not upheld in this instance, leading to a deficiency citation related to the complaint.
Failure to Accurately Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure an accurate admission assessment of a resident's pressure ulcer by a licensed nurse qualified to assess pressure wounds, as per their policy and procedure. Upon admission, the resident had a pressure ulcer that was almost healed, but it worsened to a Stage 4 ulcer by the time the resident was hospitalized. The initial assessment documented a sacrum pressure area with a yellowish and white wound bed, but it lacked details such as the stage of the ulcer and drainage observations. Subsequent documentation also failed to include comprehensive details like size, stage, odor, drainage, and description of the pressure wounds. The resident's clinical record indicated a history of flaccid neuropathic bladder, complete paraplegia, and muscle wasting and atrophy. A previous wound care note from a rehabilitation hospital documented a sacral Deep Tissue Injury that evolved to an unstageable pressure wound. The facility's policy required weekly assessments and documentation of pressure ulcers, but these were not consistently or accurately completed. The Director of Nursing noted that the previous Assistant Director of Nursing, who was responsible for wound assessments, had left the facility around the time of the resident's admission.
Improper Catheter Placement Leads to Resident Trauma
Penalty
Summary
The facility failed to ensure proper catheter care for a resident with an indwelling catheter, leading to trauma and hospitalization. Prior to the resident's hospital admission, two nurses improperly placed indwelling catheters, causing trauma to the resident's urinary tract. The first nurse inserted a catheter that was too large, resulting in blood in the catheter, necessitating its removal. Subsequently, a second nurse also inserted an oversized catheter incorrectly, which was later found to be malpositioned with the balloon inflated within the penile urethra, causing penile bleeding and hematuria. The resident, who had a medical history of flaccid neuropathic bladder, complete paraplegia, and muscle wasting, experienced significant complications due to the improper catheter placement. Nursing progress notes indicated that the catheter was initially inserted without difficulty, but later entries revealed dark red fluid in the catheter and blood clots draining into the catheter bag. A hospital emergency department report confirmed the catheter's malpositioning, and a CT scan further verified the incorrect placement. The facility's policy on catheterization was not followed, as there was no documentation of urine return or the color of the urine, which are critical steps in ensuring proper catheter placement.
Failure to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that a resident was able to access personal funds when requested, as required by their policy. Resident 36 reported that she had asked several times to withdraw money from her account but was unable to do so. An error occurred when the Corporate Business Office Manager deposited the resident's check into the Accounts Receivable (AR) side instead of the Resident Fund Management Service (RFMS) account. This mistake was compounded by the fact that the facility did not have a dedicated business office manager, and the Corporate Business Office Manager was responsible for multiple facilities. Further complications arose when Resident 36 was discharged and then readmitted to the facility, leading to issues with her funds. The resident's social security check was initially rejected by the RFMS, requiring the facility to reapply, which delayed access to her funds. Additionally, a check for $333.00 was deposited entirely into the facility's patient liability billing account, with no portion allocated to the resident's personal account. The facility's policy stated that residents should have access to their funds within three banking days, but this was not adhered to in this case.
Failure to Update Care Plan for Resident Safety
Penalty
Summary
The facility failed to ensure that a care plan was reviewed and revised appropriately for a resident who was observed with a mattress on the floor beside their bed. The resident, who had a complex medical history including seizures, schizoaffective disorder, depression, and dementia, was not observed to be on a 1:1 staff supervision as indicated in their care plan. The care plan, dated several months prior, included interventions such as 1:1 supervision and a mattress against the wall for safety, but these interventions were not being followed. The Director of Nursing confirmed that the care plan had not been updated to reflect changes in the resident's needs following their stay at an inpatient psychiatric facility. The facility's policy required that care plans be reviewed and revised by the interdisciplinary team after each assessment, but this was not done in this case, leading to the deficiency.
Failure to Administer Oxygen at Correct Flow Rate
Penalty
Summary
The facility failed to administer oxygen at the correct flow rate as ordered by the physician for two residents. Resident 32, who has a history of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, asthma, atrial fibrillation, and anxiety disorder, was observed receiving oxygen at a flow rate of 2 liters per minute (LPM) via a nasal cannula on multiple occasions. However, the physician's order and the Medication Administration Record (MAR) indicated that the resident should have been receiving 3 LPM continuously. The Assistant Director of Nursing confirmed that the oxygen was being administered at 2 LPM instead of the ordered 3 LPM. Similarly, Resident 43, diagnosed with acute respiratory failure with hypoxia, COPD, anxiety, chronic kidney disease, and arteriosclerotic heart disease, was observed receiving oxygen at a flow rate of 4 LPM and between 3 and 3.5 LPM, contrary to the physician's order of 3 LPM. The MAR also indicated that the resident should have been receiving 3 LPM. An LPN confirmed that the oxygen should have been administered at 3 LPM as per the physician's order. The facility's policy on oxygen safety emphasized that oxygen is a prescribed drug and any changes in the order must be verified by a physician before implementation.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present in the facility for at least 8 consecutive hours a day, 7 days a week, during the third quarter of 2024. Specifically, there was no RN coverage on the dates of 8/10, 8/11, 8/31, 9/1, and 9/14. A review of the Payroll-Based Journal (PBJ) staffing report confirmed the absence of licensed nursing coverage for 24 hours a day on these dates. During interviews, the Director of Nursing (DON) acknowledged that RN 2 was on call but not physically present in the building on the specified days. Additionally, the Scheduler noted that apart from management staff, the facility had only one RN who worked every other weekend. The facility did not have a specific policy for staffing, although it followed state regulations and guidelines.
Medication Unavailability Leads to Resident's Missed Doses
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident, leading to a deficiency in pharmaceutical services. Resident 4, who had a diagnosis of overactive bladder among other conditions, missed her scheduled doses of Oxybutynin for several days. The resident reported missing her medication for two days initially, which resulted in several incontinent episodes. Despite having a physician's order for daily administration of Oxybutynin, the medication was not available, and the staff informed her that the pharmacy had not delivered it. Upon further investigation, it was found that the resident went without her medication for seven days, as confirmed by the Director of Nursing. The medication was not located in the medication cart or the Emergency Drug Kit, and it was only found later in the bottom of the medication cart. The facility's policy required staff to document unavailable medications and contact the pharmacy, which was not done in this case. The resident's incontinent episodes decreased once she received her medication again.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, specifically eye drops and loose pills, in one of the medication carts reviewed. During an observation, two bottles of eye drops for a resident were found opened in the top drawer of the medication cart without any open dates on the bottles or their plastic bags. Additionally, the second drawer of the medication cart contained six loose, unidentified medications, including one large green pill, two round white pills, two oval white pills, and one small round yellow pill. A physician's order indicated that the resident was to receive one drop of prednisolone acetate ophthalmic suspension in both eyes. During an interview, a QMA confirmed that the eye drops should have been dated upon opening and that the loose medications should have been removed and destroyed. The facility's current policy on medication storage, which was undated, stated that certain medications require an expiration date shorter than the manufacturer's expiration date once opened, and that the nurse should place a date opened sticker on the medication.
Deficiencies in Food Temperature and Puree Recipe Adherence
Penalty
Summary
The facility failed to ensure that food was served at the proper temperature, that menus were followed, and that residents were offered substitutions of nutritional value of their choice. Resident 32 reported that the food often tasted terrible and was served cold, with specific instances of receiving cold fish and room temperature coleslaw. Additionally, Resident 32 noted that menu substitutions occurred routinely without being consulted for preferences. An observation confirmed that the fish was served at an inadequate temperature of 118.9 degrees, below the required 145 degrees. Resident 32's medical history includes chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and other conditions, with a BIMS score indicating cognitive intactness. The facility also failed to follow puree recipes, impacting the nutritional adequacy of meals. During observations, it was noted that the cooks did not adhere to standardized recipes for pureed foods. One cook used incorrect measurements for milk, resulting in a runny garlic bread puree, while another cook added unmeasured amounts of milk to a cake puree, leading to improper consistency. The Dietary Manager confirmed that the cooks did not follow the recipes as required by the facility's policy on pureed food preparation, which mandates the use of standardized recipes to ensure quality and nutritional value.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity by a staff member, specifically LPN 2, for four residents. Resident F requested a pain pill, and LPN 2 responded dismissively, stating she did not have time for that. Resident D was disrespected by LPN 2 when she asked to use a different shower room, and LPN 2 used profanity and told her to stay on her own hallway. Resident E did not receive her dinner tray and went to the kitchen, where LPN 2 yelled at her for being in a restricted area due to COVID-19 concerns. Resident B experienced multiple instances of disrespect from LPN 2. On one occasion, LPN 2 refused to assist him into his wheelchair and responded aggressively when he threatened to call the police. On another occasion, LPN 2 used profanity and yelled at Resident B for using his call light. These incidents were part of a pattern of behavior from LPN 2, who had multiple complaints against her for verbal aggression and unprofessional conduct towards residents. The facility's policies on resident rights and employee conduct emphasize the importance of treating residents with dignity and respect. However, LPN 2's actions violated these policies, leading to multiple complaints and ultimately her termination. The incidents highlight a failure to uphold the standards of care and respect required in the facility, impacting the residents' right to a dignified existence and self-determination.
Failure to Protect Residents from Theft
Penalty
Summary
The facility failed to ensure a resident was free from theft, as evidenced by a staff member not returning change after purchasing food for a resident. Resident C gave CNA 3 fifty dollars to purchase Taco Bell, but the CNA did not return the change. The investigation revealed that CNA 3 was given fifteen dollars for the food and ten dollars for gas, but kept the remaining money. Resident C reported that this was not the first time CNA 3 had asked to keep money for gas. The facility reimbursed Resident C for the ten dollars taken by CNA 3, who was subsequently terminated for violating company policy. Another incident involved Resident K, who gave CNA 3 four dollars to purchase a candy bar and a drink from the vending machine. The CNA did not return the sixty-five cents in change. The facility's investigation partially substantiated the concern, and CNA 3 admitted to placing the change in the resident's room. The facility's policy prohibits staff from taking money from residents, and CNA 3 was terminated for this violation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kokomo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kokomo Healthcare Center | 0.8 mi | — | 7 | 0 |
| Wellbrooke Of Kokomo | 2.2 mi | — | 11 | 0 |
| North Woods Village | 3.5 mi | — | 7 | 0 |
| Brickyard Healthcare -sycamore Village Care Center | 3.7 mi | — | 10 | 0 |
| Waterford Place Health Campus | 3.8 mi | — | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.