Cycle 1
Health 2026-02-02 · Fire 2025-02-17
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Kokomo, IN
Waterford Place Health Campus
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
800 St Joseph Dr, Kokomo, IN
(765) 236-1239
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
103
Certified beds
Average residents
78
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2000-09-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 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
0.62
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.52
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,154
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.55% · Performance 21.47% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.63% · Performance 7.86% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.73
Baseline 34.04% · Performance 40.26% · Measure score 5.73 · Achievement 5.73 · Improvement 0
Adjusted total nurse staffing
1.41
Baseline 2.20 hours · Performance 2.89 hours · Measure score 1.41 · Achievement 0 · Improvement 1.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.85% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 310 · Observed rate 7.74% · Lower 95% interval 7% |
| Discharge to community | 61.67% |
50.57%
11.1 pts better
|
Better than the National Rate · Eligible stays 305 · Observed rate 58.69% · Lower 95% interval 56.56% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.49% |
95.27%
4.2 pts better
|
Numerator 195 · Denominator 196 |
| Falls with major injury | 1.02% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 196 |
| Discharge self-care score | 72.79% |
53.69%
19.1 pts better
|
Numerator 107 · Denominator 147 |
| Discharge mobility score | 65.99% |
50.94%
15 pts better
|
Numerator 97 · Denominator 147 |
| Pressure ulcers or injuries, new or worsened | 1.02% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 196 · Adjusted rate 0.74% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 201 · Observed rate 7.46% · Lower 95% interval 4.65% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 148 |
| Staff flu vaccination coverage | 2.44% |
42%
39.6 pts worse
|
Numerator 5 · Denominator 205 |
| Discharge function score | 73.47% |
56.45%
17 pts better
|
Numerator 108 · Denominator 147 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 94 · Denominator 94 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 70 · Denominator 70 |
| Resident COVID-19 vaccinations up to date | 31.4% |
25.2%
6.2 pts better
|
Numerator 27 · Denominator 86 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
93.6%
4.1 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 98.1% · Q3 98.1% · Q4 98.1% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
95.4%
2.9 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.8%
2.4 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 1.9% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 36.5% |
24.6%
11.9 pts worse
|
11.4%
25.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.1% · Q2 41.5% · Q3 27.5% · Q4 27.3% · 4Q avg 36.5% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.6%
1.6 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.9% · Q3 4.4% · Q4 0.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.5% |
23.5%
3 pts worse
|
19.6%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 23.9% · Q3 26.7% · Q4 27.9% · 4Q avg 26.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
14.8%
8.7 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 2.6% · Q3 5.1% · Q4 6.9% · 4Q avg 6.1% · 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 | 11.7% |
13.3%
1.6 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.9% |
11.7%
8.8 pts better
|
14.9%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 4.7% · Q4 2.4% · 4Q avg 2.9% · 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 | 24.3% |
24.2%
0.1 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 33.1% · Q3 21.5% · Q4 17.9% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.1%
0.8 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.6% · Q3 2.1% · Q4 2.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
81.6%
9.8 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.6% · Q2 94.0% · Q3 91.6% · Q4 86.8% · 4Q avg 91.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
10.5%
2.9 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.6% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.0% · Q3 0.0% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.7% |
79.0%
4.7 pts better
|
79.7%
4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.3% |
22.4%
7.9 pts worse
|
23.9%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 28.9% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-17 · Fire 2024-01-09
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2024-01-09 · Fire 2022-11-21
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-02-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-02-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-02-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-02-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-17
K251 · Egress Deficiencies
Fire Safety
Conform to length requirements for dead end corridors.
Corrected 2025-04-04
F · Potential for more than minimal harm
2024-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-01-09
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-01-09
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 2024-03-06
E · Potential for more than minimal harm
2024-01-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-01-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-01-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-06
F · Potential for more than minimal harm
2022-11-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-30
E · Potential for more than minimal harm
2022-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-30
D · Potential for more than minimal harm
2022-11-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-01-30
D · Potential for more than minimal harm
2022-11-21
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 2023-01-30
D · Potential for more than minimal harm
2022-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-02-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-02-02
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-02-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-02-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-20
E · Potential for more than minimal harm
2025-02-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-16
E · Potential for more than minimal harm
2025-02-17
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-16
D · Potential for more than minimal harm
2025-02-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-16
D · Potential for more than minimal harm
2024-01-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-31
Penalties and ownership
What sits behind the stars
Ownership
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bardoczi, Stephen
Corporate Officer · Individual
Barney, Leigh
Limited Partnership Interest · Individual
Bayston, Brett
Corporate Director · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Davis, David
Limited Partnership Interest · Individual
Hawkins, Claude
Corporate Director · Individual
Hornbecker, Michael
Corporate Director · Individual
Lument Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Nieves, Alma
Operational/Managerial Control · Individual
Ravindra, Baikadi
Operational/Managerial Control · Individual
Reagan, Julie
Corporate Director · Individual
Sellers, Daniel
Corporate Officer · Individual
Trilogy Healthcare Of Kokomo LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
North Woods Village
Kokomo, IN
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
#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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