Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 North Woods Village during CMS and state inspections, most recent first.
Two residents with orders for narcotic pain medications experienced misappropriation of their medications when an LPN removed narcotics from the medication cart, concealed them, and left her shift without conducting the required medication count or reporting to incoming staff. The theft was discovered when another nurse attempted to administer medication and found both the narcotics and count sheets missing, in violation of facility policy.
A facility failed to follow a physician's order to hold midodrine, a blood pressure medication, for a resident when their systolic blood pressure exceeded 120. Despite the order, the medication was administered multiple times over several months when the resident's blood pressure was above the specified threshold. An LPN confirmed that vital signs should be reviewed before medication administration, and the facility's policy supported this practice.
A facility failed to ensure a resident's portable oxygen tank was turned on to the correct flow rate, as required by a physician's order. The resident, diagnosed with chronic respiratory conditions, was observed with a nasal cannula and an oxygen tank set at zero liters per minute. Despite interactions with staff, the oxygen flow was not verified, contrary to facility policy.
A QMA failed to follow infection control protocols by handling a resident's medication with bare hands instead of using gloves. The resident had diagnoses including diabetes mellitus and atrial fibrillation. Facility policy requires medications to only contact the medication cup and mandates hand hygiene before and after resident contact.
The facility failed to notify a resident's representative of a psychotic disturbance and the initiation of an antipsychotic medication. Despite multiple physician's orders to administer Risperdal for dementia with psychotic disturbance, there was no documentation indicating that the resident's representative was informed about the medication or its risks and benefits. The Director of Nursing Services confirmed the lack of notification, which was against the facility's policy.
The facility failed to correctly code an annual MDS assessment for a resident with multiple diagnoses, including dementia and bipolar disorder. The assessment incorrectly indicated that the resident was not considered by the state level 2 PASARR process to have a serious mental illness. The SSD acknowledged the error, and the DNS confirmed the use of the RAI manual for assessments.
The facility failed to ensure a resident's oxygen was set to the correct liter flow as per the physician's orders. The resident's oxygen was observed at 1 liter instead of the prescribed 2 liters, despite a history of inconsistent oxygen usage and no evidence that the resident adjusted the concentrator.
The facility failed to document and implement nonpharmacological interventions for a resident with dementia, who exhibited continuous fidgety behavior and was on Risperdal. The staff did not consistently document the resident's behaviors or the interventions used, and the AIMS assessment for monitoring adverse side effects was not properly conducted.
The facility failed to store clean clothing and personal care items in a clean environment for four residents. Observations revealed that clean clothes were hanging in bathrooms, touching the toilet armrest, and within the contamination splash zone. Additionally, a bathroom had a strong odor of urine and bowel movement, with dirty sink handles and a bathtub used for storing clean supplies. The facility's policy emphasized preventing contamination, but these guidelines were not followed, posing a risk to residents' health.
Narcotic Medication Theft by Staff Member
Penalty
Summary
The facility failed to ensure that narcotic medications were protected from theft by an employee, resulting in the misappropriation of controlled substances prescribed to two residents. One resident, with diagnoses including a pathological fracture, malignant neoplasms, osteoarthritis, and anxiety disorder, had an active order for oxycodone for pain management. Another resident, with acute pain due to trauma and multiple fractures, also had an order for oxycodone-acetaminophen for pain relief. Both residents were found to have missing narcotic medications and associated count sheets. The events leading to the deficiency involved an LPN who, during her shift, was observed on facility video surveillance removing narcotics from the medication cart, concealing them in a jacket, and subsequently placing the jacket in a bag at the nurse's station. The LPN also took the narcotic count sheet book from the cart, brought it to the locked medication room, and then returned it to the cart. The LPN left her shift early without waiting for a replacement nurse, failed to conduct a medication count with the incoming staff, and did not provide a report on the residents prior to leaving the facility. Interviews and record reviews confirmed that the missing medications were discovered when another nurse attempted to administer a pain pill and found both the narcotics and the count sheet missing. The pharmacy verified that the medications should have been available, and the incident was reported to the DON. Facility policies required shift change verification and dual staff counts of controlled substances, but these procedures were not followed, allowing the theft to occur.
Failure to Hold Medication as Ordered for Blood Pressure
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of midodrine, a medication used to increase blood pressure, for a resident with multiple diagnoses including paraplegia, neuromuscular dysfunction of the bladder, familial dysautonomia, and chronic systolic congestive heart failure. The physician's order specified that the medication should be withheld if the resident's systolic blood pressure exceeded 120. However, the Medication Administration Record (MAR) indicated that the medication was administered on multiple occasions despite the resident's systolic blood pressure being above the specified threshold. The deficiency was identified through a review of the resident's clinical records and interviews with facility staff. The records showed numerous instances in January, February, and March where the medication was not held despite the resident's systolic blood pressure readings exceeding 120. An LPN confirmed during an interview that vital signs and medication orders should be reviewed before administering medication, and if the blood pressure was above the hold parameter, the medication should not be given. The facility's policy on medication administration also emphasized the need to obtain vital signs prior to administering medication.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a portable oxygen tank was turned on to administer the correct flow rate for a resident requiring respiratory care. During an observation, the resident was seen in the hallway with a nasal cannula in her nose and a portable oxygen tank on her wheelchair, which was set at zero liters per minute. Despite receiving medications from a QMA, the oxygen flow rate was not checked. Later, the resident was observed entering the dining room with the oxygen tank still set at zero liters per minute. The resident's clinical record indicated diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and asthma, with a physician's order for continuous oxygen at 4 liters per minute. Interviews with facility staff revealed that the responsibility to ensure the correct oxygen flow rate was not consistently followed. The facility's policy required nurses to coordinate oxygen therapy as ordered by the physician, but this was not adhered to in the case of the resident.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration for one resident. During an observation, a Qualified Medication Aide (QMA) was seen removing a multivitamin pill from its packaging and placing it into a medication cup using her bare hands, without wearing gloves. The QMA acknowledged that she should have used gloves and not touched the pill with her bare hands. The resident involved had a clinical record indicating diagnoses of diabetes mellitus, atrial fibrillation, and anxiety disorder. The facility's policy on medication administration, which was revised recently, specifies that medications should not come into contact with any surface except for the medication cup, and appropriate hand hygiene should be performed before and after direct resident contact.
Failure to Notify Resident's Representative of Antipsychotic Medication
Penalty
Summary
The facility failed to notify the resident's representative of a psychotic disturbance and the initiation of an antipsychotic medication for Resident 89. The resident had multiple diagnoses, including a nondisplaced fracture of the right femur, major depressive disorder, generalized anxiety disorder, cognitive communication deficit, and dementia with psychotic disturbance. A physician's order was given on three separate occasions to administer Risperdal at increasing dosages to manage the resident's dementia with psychotic disturbance. However, there was no documentation indicating that the resident's representative was informed about the start of the antipsychotic medication or the associated risks and benefits. A Pharmacy Consultation Report recommended discontinuing Risperdal due to the increased risk of mortality in older adults with dementia-related psychosis, but this recommendation was declined by the prescriber. The Psychiatric Nurse Practitioner noted that the resident exhibited delusional thinking and symptoms of depression, which led to the decision to start Risperdal. Despite these observations, the facility's progress notes did not include any notification to the resident's representative. The Director of Nursing Services confirmed the lack of documentation regarding the notification. The facility's policy on resident change of condition mandates that all changes be communicated to the physician and family/responsible party, but this protocol was not followed in this instance.
Incorrect Coding of MDS Assessment for Resident with PASARR Level 2
Penalty
Summary
The facility failed to correctly code an annual Minimum Data Set (MDS) assessment for a resident reviewed for Preadmission Screening and Resident Review (PASARR). The resident had multiple diagnoses, including unspecified dementia with mood disturbance, insomnia, bipolar disorder, major depressive disorder, and psychotic disorder with delusions. A PASARR level 2 outcome notice indicated the resident had a long-term approval without specialized services based on these diagnoses. However, the annual MDS assessment incorrectly indicated that the resident was not considered by the state level 2 PASARR process to have a serious mental illness and/or intellectual disability or related condition. During interviews, the Social Services Director (SSD) acknowledged that the MDS assessment was marked in error and should have been marked as a yes. The Director of Nursing Services (DNS) confirmed that the facility used the Resident Assessment Instrument (RAI) manual for MDS assessments. The CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual emphasizes the importance of accurate information and validation by the interdisciplinary team (IDT) completing the assessment. The facility failed to ensure that all participants in the assessment process had the requisite knowledge to complete an accurate assessment.
Failure to Ensure Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure a resident's oxygen was set to the correct liter flow as per the physician's orders. During an observation, it was noted that the resident's oxygen was set at 1 liter flow, while the physician's order required 2 liters per nasal cannula continuously. The resident's clinical record indicated diagnoses including COPD, chronic respiratory failure with hypoxia, and influenza due to novel influenza A virus. The physician's order was changed to 2 liters at bedtime, but the resident's oxygen was still observed at 1 liter. Historical oxygen saturation results showed inconsistencies in oxygen usage, with instances where oxygen was either not used or set at different flow rates. The resident indicated she did not adjust her oxygen concentrator, and there was no documentation suggesting she had done so before. The facility's policy on oxygen concentrators emphasized verifying and understanding the physician's orders and knowing the flow rate and duration of use.
Failure to Document and Implement Nonpharmacological Interventions for Resident with Dementia
Penalty
Summary
The facility failed to ensure proper documentation and implementation of nonpharmacological interventions for a resident with dementia. The resident exhibited continuous fidgety behavior and was observed rocking back and forth in her wheelchair, pulling at a blanket, and making constant movements with her hands. Despite these behaviors, the staff did not document them in the electronic health record (EHR) as required. Additionally, the staff did not document the nonpharmacological interventions used to address the resident's behaviors, such as offering a snack or providing personal space. The resident's clinical record indicated a history of severe cognitive impairment, anxiety disorder, delusional disorder, and other mental health conditions. The resident was on Risperdal, an antipsychotic medication, and had experienced a failed gradual dose reduction (GDR) of the medication. The staff reported increased aggression, agitation, delusions, and hallucinations following the GDR, but these behaviors were not consistently documented in the EHR. The lack of documentation made it difficult to assess the resident's response to the medication changes and the effectiveness of nonpharmacological interventions. The facility's policies on behavior management and psychotropic medication management were not followed. The staff did not document new or worsening behaviors in the EHR, and the AIMS assessment for monitoring adverse side effects of antipsychotic medication was not properly conducted. The Dementia Unit Manager was unaware of the correct procedures for completing the AIMS assessment, leading to incomplete evaluations. The Director of Nursing Services acknowledged the lack of documentation and training on AIMS assessments, contributing to the deficiency in care for the resident with dementia.
Improper Storage of Clean Items in Contaminated Areas
Penalty
Summary
The facility failed to store clean clothing and personal care items in a clean environment for four residents. Observations revealed that clean clothes were hanging from the shower curtain rod over the bathtub in the bathroom of two residents, with some items touching the armrest of the toilet and within the contamination splash zone of the flushing toilet. The Assistant Director of Nursing Services was unaware of why the clothes were stored in the bathroom, and the Executive Director confirmed that clean clothing should not be stored in bathrooms or bathtubs. The Infection Preventionist stated that clean laundry and linens should be covered during transport and stored in closets. The clinical records of the residents involved indicated various medical conditions, including cellulitis, chronic ulcers, and pressure ulcers, which could be exacerbated by improper storage of clean items in contaminated areas. Additionally, the bathroom for two other residents had a strong odor of urine and bowel movement, with dirty and rusty sink handles. The bathtub in this bathroom was covered with plywood and used for storing clean personal care supplies. The Executive Director was unsure why the plywood was there and confirmed that clean items should not be stored in the bathtub. The facility's policy on laundry and linen handling emphasized the importance of preventing contamination by storing clean linen appropriately. The report also referenced a Splash Zone Information Sheet, which highlighted the risk of contamination from splashes occurring up to three feet from sinks, toilets, or drains. This information underscored the importance of avoiding the storage of supplies within the splash zone to prevent the spread of multidrug-resistant organisms. The facility's failure to adhere to these guidelines resulted in the improper storage of clean items in contaminated areas, posing a risk to the residents' health and safety.
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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) |
|---|---|---|---|---|
| Waterford Place Health Campus | 0.3 mi | — | 11 | 0 |
| Brickyard Healthcare -sycamore Village Care Center | 0.7 mi | — | 10 | 0 |
| Wellbrooke Of Kokomo | 2.1 mi | — | 11 | 0 |
| Kokomo Healthcare Center | 2.8 mi | — | 7 | 0 |
| Aperion Care Kokomo | 3.5 mi | — | 1 | 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.