Cycle 1
Health 2025-03-06 · Fire 2025-03-06
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Kokomo, IN
North Woods Village
3-star overall rating with 3-star inspections with $24,291 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2233 W Jefferson St, Kokomo, IN
(765) 457-9175
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
155
Certified beds
Average residents
111
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
1972-11-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
91 facilities
Chain averages 4 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
2.54
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,433
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.93
Baseline 17.46% · Performance 20.08% · Measure score 2.93 · Achievement 2.93 · Improvement 0
Healthcare-associated infections
2.21
Baseline 5.19% · Performance 7.17% · Measure score 2.21 · Achievement 2.21 · Improvement 0
Total nurse turnover
7.66
Baseline 43.69% · Performance 32.38% · Measure score 7.66 · Achievement 7.66 · Improvement 5.50
Adjusted total nurse staffing
0.35
Baseline 2.58 hours · Performance 2.85 hours · Measure score 0.35 · Achievement 0 · Improvement 0.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.55% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 13.79% · Lower 95% interval 7.43% |
| Discharge to community | 47.56% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 42.59% · Lower 95% interval 36.67% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 56 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 46.67% |
53.69%
7 pts worse
|
Numerator 21 · Denominator 45 |
| Discharge mobility score | 48.89% |
50.94%
2 pts worse
|
Numerator 22 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 8.93% |
2.29%
6.6 pts worse
|
Numerator 5 · Denominator 56 · Adjusted rate 7.76% |
| Healthcare-associated infections requiring hospitalization | 7.17% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 44 · Observed rate 6.82% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 151 |
| Staff flu vaccination coverage | 28.17% |
42%
13.8 pts worse
|
Numerator 40 · Denominator 142 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 25 · Denominator 45 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 21.21% |
25.2%
4 pts worse
|
Numerator 7 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.8%
2.2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 0.0% · Q4 2.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 54.8% |
24.6%
30.2 pts worse
|
11.4%
43.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 56.6% · Q2 59.8% · Q3 48.9% · Q4 53.3% · 4Q avg 54.8% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
5.6%
3.9 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.5% · Q3 11.4% · Q4 6.2% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.9% |
23.5%
13.4 pts worse
|
19.6%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.1% · Q2 35.9% · Q3 35.4% · Q4 34.9% · 4Q avg 36.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
14.8%
6.3 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.6% · Q3 9.9% · Q4 10.1% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 0.5% |
13.3%
12.8 pts better
|
16.3%
15.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.4% |
11.7%
10.3 pts better
|
14.9%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 4.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
24.2%
0.5 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 30.4% · Q3 11.8% · Q4 30.5% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.1%
0.5 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.1% · Q3 3.4% · Q4 5.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
81.6%
17.7 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 99.1% · Q3 99.1% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.5% |
10.5%
6 pts better
|
12.0%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.5% · Observed 4.3% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.0%
21 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
22.4%
2.2 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 17.0% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2022-12-20 · Fire 2022-12-20
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-03-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-03-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-03-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-10
B · Minimal harm
2025-03-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-10
F · Potential for more than minimal harm
2024-03-15
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-03-15
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-03-15
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-03-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-03-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-03-15
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-03-15
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-03-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-03-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-03-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-03-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-03-15
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-01
D · Potential for more than minimal harm
2024-03-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-01
C · Minimal harm
2024-03-15
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-06-01
C · Minimal harm
2024-03-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-01
F · Potential for more than minimal harm
2022-12-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-30
E · Potential for more than minimal harm
2022-12-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-30
D · Potential for more than minimal harm
2022-12-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-16
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Not marked corrected
D · Potential for more than minimal harm
2025-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
D · Potential for more than minimal harm
2024-03-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-15
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-15
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-11
J · Immediate jeopardy
2024-01-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-01
D · Potential for more than minimal harm
2022-12-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-07
Penalties and ownership
What sits behind the stars
$24,291
2024-01-11
Fine
Fine · fine $24,291
Fine
Ownership
The Health And Hospital Corporation Of Marion County
5% Or Greater Direct Ownership Interest · Organization
American Senior Communities LLC
Operational/Managerial Control · Organization
Babcock, Paul
Operational/Managerial Control · Individual
Babcock, Paul
Corporate Officer · Individual
Caine, Virginia
Corporate Officer · Individual
Dice, Mark
Operational/Managerial Control · Individual
Doucet, Kelly
Corporate Director · Individual
Drummer, Carl
Corporate Director · Individual
Fisch, Gary
Corporate Director · Individual
Goddard, Nichole
Operational/Managerial Control · Individual
Goddard, Nichole
Corporate Officer · Individual
Hanify, Thomas
Corporate Director · Individual
Harris, Lisa
Corporate Officer · Individual
Head, Stephanie
Operational/Managerial Control · Individual
Heath, Amy
Operational/Managerial Control · Individual
Horn, Brenda
Corporate Director · Individual
Lazard, Robert
Corporate Director · Individual
O'brien, Michael
Corporate Director · Individual
Sedaghat, Vahid-David
Operational/Managerial Control · Individual
Shane, Andrew
Operational/Managerial Control · Individual
Simpson, James
Operational/Managerial Control · Individual
Simpson, James
Corporate Officer · Individual
The Health And Hospital Corporation Of Marion County
Operational/Managerial Control · Organization
Van Camp, Steven
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Waterford Place Health Campus
Kokomo, IN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Brickyard Healthcare -Sycamore Village Care Center
Kokomo, IN
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Wellbrooke Of Kokomo
Kokomo, IN
4-star overall rating with 3-star inspections with $8,824 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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