Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Waterford Place Health Campus during CMS and state inspections, most recent first.
The facility failed to follow physician orders and internal policies for weight monitoring and physician notification. A resident with multiple cardiopulmonary conditions had numerous missed daily weights despite an order and care plan requiring daily weighing. Two residents admitted with complex medical histories, including severe malnutrition and prior CVA, did not have admission weights obtained within the expected 24-hour timeframe, with one weight delayed several days. Another resident with DM and a right fibula fracture had an order for Humalog insulin per sliding scale with instructions to call the physician for blood glucose values outside a specified range, but a critically elevated blood sugar was not reported to the NP until days later. Staff interviews and facility policies confirmed that daily and admission weights, as well as timely provider notification, were required but not consistently carried out.
A resident with multiple medical and behavioral health diagnoses, including depression, vascular dementia, PTSD, and an adjustment disorder with anxiety, was started on diazepam twice daily for anxiety without a timely PASARR Level I screen. The PASARR assessment related to the new anxiety diagnosis and new antianxiety medication was not completed until after the survey had begun, despite the Administrator’s acknowledgement that a new Level I is required when a new psychotropic medication or mental health diagnosis is added and facility policy directing contact with the PASARR office for such behavioral health conditions.
A resident with a Foley catheter and history of UTI was observed with the catheter drainage bag attached to a trash can containing trash, and the urine in the tubing appeared cloudy with sediment. The resident’s care plan identified neurogenic bladder and the need to observe catheter tubing, and the resident was on ciprofloxacin for a UTI. Facility staff, including the ADON, Medical Record Nurse, and a QMA, acknowledged that the catheter bag should be hung on the bed rail and not on a trash can, and that this practice placed the resident at risk of infection, contrary to the facility’s urinary catheter care policy.
A resident with a history of UTI and multiple comorbidities, including acute kidney failure and urinary retention, was observed with an indwelling catheter drainage bag attached to a trash can containing trash, with cloudy urine and sediment noted in the tubing. The ADON, Medical Record Nurse, and a QMA all acknowledged that the catheter bag should not be placed on a trash can and should instead be hung on the bed rail, stating that this practice placed the resident at risk of infection. This practice was inconsistent with the facility’s Infection Prevention and Control Program, which is intended to prevent the development and transmission of infections and monitor compliance with infection control procedures.
The facility failed to administer oxygen at the physician's ordered level for four residents. A resident had varying oxygen levels set on her concentrator, contrary to the physician's order for 2 liters as needed. Another resident was observed with an oxygen concentrator set at 3 liters, despite an order for 2 liters continuously. A third resident had no physician's order for oxygen until after the survey start date, yet was observed with oxygen levels between 3.5 and 7 liters. Similarly, another resident was observed with 3.5 liters of oxygen without a physician's order until after the survey start date.
The facility failed to maintain a clean and sanitary environment, with strong odors, unsecured outlets, and blood smears observed in resident rooms. Hallways were cluttered with equipment due to insufficient storage. Staff were aware of these issues, but actions to address them were delayed or insufficient.
The facility failed to follow physician orders for three residents, leading to deficiencies in care. A resident received metoprolol despite low blood pressure, and hospice was not notified of high blood glucose levels. Another resident also received metoprolol against hold parameters. A third resident's blood glucose was not monitored as ordered. Staff interviews confirmed these oversights.
Failure to Obtain Ordered and Admission Weights and Notify Physician of Critical Blood Glucose
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document ordered weights and to notify the physician as ordered, as well as delays in obtaining admission weights. For one resident with acute respiratory failure with hypoxia, COPD with exacerbation, heart failure, fluid overload, chronic kidney disease, and acute pulmonary edema, a physician’s order dated 12/2/25 required a daily weight once a day, and the care plan reflected this order. However, the MAR for December and January showed multiple days on which the daily weight was not obtained or documented. Facility staff, including a QMA and the DON, stated that daily weights should be completed every day, typically in the morning before breakfast. Another resident with severe protein-calorie malnutrition, encephalopathy, pneumonia, rhabdomyolysis, atherosclerotic heart disease, ischemic cardiomyopathy, repeated falls, hypovolemic shock, and gastrostomy status had physician’s orders on consecutive days to obtain an admission weight, but the admission weight of 106.5 pounds was not obtained and documented until six days after admission, contrary to staff statements that admission weights should be completed on the day of admission or within 24 hours. A third resident with diabetes mellitus and a right fibula fracture had a care plan indicating use of hypoglycemia medication and risk for adverse effects, with interventions including administering medication as ordered. A physician’s order directed staff to administer Humalog insulin per sliding scale and to call the physician for blood sugars less than 60 or greater than 400. The clinical record showed a blood sugar of 435, but the NP was not notified until several days later, as documented in an IDT note and confirmed by the Clinical Support Nurse. A fourth resident with a history of UTI and cerebrovascular accident had an admission weight of 165 pounds obtained and documented several days after admission, despite facility policy and staff statements that admission observation and data collection, including weight, should be initiated within 12 hours and completed within 24 hours. Facility policies on admission nursing observation and weight monitoring required timely completion of admission assessments and daily review of missing admission and ordered weights, but the records for these residents showed that these processes were not followed as required.
Failure to Complete Timely PASARR Level I for New Mental Health Diagnosis and Psychotropic Medication
Penalty
Summary
The facility failed to ensure a timely PASARR (Preadmission Screening and Resident Review) Level I screen was completed when a resident had a new mental health diagnosis and was prescribed a new psychotropic medication. The clinical record for Resident 4 showed multiple diagnoses including depression, atrial fibrillation, heart disease, vascular dementia, pseudobulbar affect, post-traumatic stress disorder (PTSD), and adjustment disorder with anxiety. A physician’s order dated 9/19/25 directed administration of diazepam 2 mg twice daily for anxiety, but a PASARR Level I screen related to the new anxiety disorder diagnosis and the new antianxiety medication was not completed until 2/2/26, after the survey had begun. During interview, the Administrator stated that when a resident has a new psychotropic medication or a new mental health diagnosis added, a new Level I PASARR is required, confirming that this was not done until 2/2/26 for this resident. The facility’s PASARR Quick Sheet policy indicated that when an individual has a severe mental illness/behavioral health diagnosis such as major depressive disorder or anxiety disorder, and the diagnosis is given by a psychiatric provider, the PASARR office should be contacted, but this process was not followed in a timely manner for Resident 4’s new anxiety diagnosis and diazepam order.
Improper Positioning and Sanitary Maintenance of Foley Catheter Drainage Bag
Penalty
Summary
Surveyors observed that a resident with a Foley catheter had the urinary drainage bag attached to a trash can next to the bed. The trash can contained trash in the bottom, and the urine in the catheter tubing was described as cloudy with sediment. The resident’s clinical record showed diagnoses including a history of UTI, acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, COPD, urinary retention, and atrial fibrillation. The care plan indicated the resident had a Foley catheter related to neurogenic bladder, with interventions that included observing the catheter tubing. A recent physician’s order documented that the resident was receiving ciprofloxacin 500 mg twice daily for 14 days for a UTI. Facility staff, including the ADON, Medical Record Nurse, and a QMA, each stated in interviews that the catheter bag should not be placed on a trash can and should instead be hung on the bed rail, and that placing the bag on the trash can put the resident at risk of infection. The facility’s urinary catheter care policy required checking urine for unusual appearance, keeping the drainage bag positioned lower than the bladder to prevent backflow, and ensuring the catheter and tubing were free of kinks, but did not direct staff to place the bag on a trash can.
Improper Catheter Bag Placement on Trash Can
Penalty
Summary
Surveyors observed that a resident’s indwelling urinary catheter drainage bag was improperly attached to a trash can next to the bed. The urine in the catheter tubing was described as cloudy with sediment, and the trash can being used to support the bag contained trash in the bottom. The resident’s clinical record showed diagnoses including a history of urinary tract infection (UTI), acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, chronic obstructive pulmonary disease, urinary retention, and atrial fibrillation. A recent physician’s order documented that the resident had been prescribed ciprofloxacin 500 mg twice daily for 14 days for a UTI. During interviews, the ADON stated the catheter bag should not be placed on the trash can and acknowledged that the resident had a history of UTI and that placing the catheter bag on the trash can could contribute to infection. The Medical Record Nurse also indicated the catheter bag was not supposed to be on the trash can and that the resident was at risk of infection. A QMA confirmed that the catheter bag should be hung on the bed rail and never on the trash can, explaining that hanging the bag on a dirty trash can would put the resident at risk of developing a major infection. The facility’s Infection Prevention and Control Program policy indicated it was designed to help prevent the development and transmission of communicable diseases and infections and to monitor compliance with infection control practices and procedures, which was not followed in this instance.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician's ordered level for four residents. Resident 118 was observed with varying oxygen levels set on her concentrator, ranging from 0.5 to 3 liters, despite a physician's order for 2 liters as needed. The LPN was unsure of the resident's oxygen order, and the care plan indicated the need to administer oxygen per the physician's order. Resident 51 was observed with an oxygen concentrator set at 3 liters, although the physician's order specified 2 liters continuously. Documentation showed multiple instances where the resident was on 3 liters, and once on 1.5 liters, contrary to the physician's order. The care plan required oxygen administration according to the physician's order. Resident 9 was observed with oxygen levels set between 3.5 and 7 liters, but there was no physician's order for oxygen until after the survey start date. Similarly, Resident 58 was observed with 3.5 liters of oxygen without a physician's order until after the survey start date. The facility's policy required verification of the physician's order for oxygen administration, which was not adhered to in these cases.
Environmental Deficiencies in Resident Rooms and Hallways
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in several resident rooms and hallways. Observations revealed strong odors of urine and bowel movements in the 100-hallway and rooms, as well as peeling paint and cracks on the wall in one room. Another room had an unsecured electrical outlet with cords plugged in, and a large dried blood smear was found on the wall and sheets in a different room, accompanied by flying bugs. The Maintenance Director acknowledged previous repairs to the outlet, which had been damaged by staff moving the bed. The Regional Support Executive Director confirmed a sewer backup in one room's bathroom, contributing to the presence of bugs. Additionally, the 200-hallway was cluttered with mechanical lifts and wheelchairs due to a lack of storage space, as confirmed by the Regional Support Executive Director. The facility did not have an environmental policy and relied on state guidelines. Interviews with staff indicated awareness of the issues, but actions to address them were delayed or insufficient. The facility's policy on resident rights emphasized dignity and respect, yet the observed conditions contradicted these principles.
Failure to Follow Physician Orders for Medication and Monitoring
Penalty
Summary
The facility failed to adhere to physician's orders for three residents, leading to deficiencies in care. For Resident 30, the facility did not follow the hold parameters for metoprolol tartrate, a medication used to treat high blood pressure, as it was administered despite systolic blood pressure readings below the specified threshold. Additionally, the facility did not notify hospice of blood glucose readings exceeding 250, as required by the physician's order. Interviews with staff confirmed the oversight in following these orders. Resident 54 also experienced a similar issue with the administration of metoprolol tartrate. The medication was given despite systolic blood pressure readings being below the hold parameter of 110, as specified in the physician's order. This was documented multiple times in the Medication Administration Record, and staff interviews confirmed that vital signs should have been checked and hold parameters followed. For Resident 24, the facility failed to obtain and document a 4:00 a.m. blood glucose reading as ordered by the physician to prevent hypoglycemia. The order was entered incorrectly into the electronic health record, and there was no documentation of the reading being obtained or the physician being notified of the oversight. Interviews with nursing staff and the Director of Nursing revealed a lack of policy for blood glucose monitoring and a failure to verify and enter orders correctly.
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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) |
|---|---|---|---|---|
| North Woods Village | 0.3 mi | — | 7 | 0 |
| Brickyard Healthcare -sycamore Village Care Center | 0.7 mi | — | 10 | 0 |
| Wellbrooke Of Kokomo | 2.3 mi | — | 11 | 0 |
| Kokomo Healthcare Center | 3 mi | — | 7 | 0 |
| Aperion Care Kokomo | 3.8 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.