Cycle 1
Health 2025-03-18 · Fire 2025-03-18
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Kokomo, IN
Wellbrooke Of Kokomo
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
2200 South Dixon Road, Kokomo, IN
(765) 455-4443
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2014-05-13
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
1.14
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
2.90
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,063
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9862
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.28
Baseline 20.56% · Performance 20.84% · Measure score 1.28 · Achievement 1.28 · Improvement 0
Healthcare-associated infections
7.68
Baseline 7.44% · Performance 5.54% · Measure score 7.68 · Achievement 7.68 · Improvement 7.27
Total nurse turnover
2.81
Baseline 50.70% · Performance 52.17% · Measure score 2.81 · Achievement 2.81 · Improvement 0
Adjusted total nurse staffing
0.57
Baseline 2.64 hours · Performance 2.98 hours · Measure score 0.57 · Achievement 0 · Improvement 0.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 463 · Observed rate 9.5% · Lower 95% interval 7.16% |
| Discharge to community | 68.22% |
50.57%
17.6 pts better
|
Better than the National Rate · Eligible stays 453 · Observed rate 65.34% · Lower 95% interval 64.15% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 254 · Denominator 254 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 2 · Denominator 254 |
| Discharge self-care score | 75.39% |
53.69%
21.7 pts better
|
Numerator 144 · Denominator 191 |
| Discharge mobility score | 62.83% |
50.94%
11.9 pts better
|
Numerator 120 · Denominator 191 |
| Pressure ulcers or injuries, new or worsened | 0.39% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 254 · Adjusted rate 0.38% |
| Healthcare-associated infections requiring hospitalization | 5.54% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 273 · Observed rate 3.66% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 100 |
| Staff flu vaccination coverage | 37.41% |
42%
4.6 pts worse
|
Numerator 52 · Denominator 139 |
| Discharge function score | 75.39% |
56.45%
18.9 pts better
|
Numerator 144 · Denominator 191 |
| Transfer of health information to provider | 99.39% |
95.95%
3.4 pts better
|
Numerator 164 · Denominator 165 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 72 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 5.13% |
25.2%
20.1 pts worse
|
Numerator 6 · Denominator 117 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
93.6%
1.5 pts better
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.8%
2.8 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
24.6%
19.4 pts better
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
5.6%
5 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.6% |
23.5%
7.1 pts worse
|
19.6%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.7% |
14.8%
10.1 pts better
|
16.7%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
11.7%
1.3 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
24.2%
6 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.1%
1.8 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.3% |
81.6%
6.7 pts better
|
81.7%
6.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 94.3% · Q3 89.3% · Q4 73.5% · 4Q avg 88.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.2% |
10.5%
9.7 pts worse
|
12.0%
8.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 17.7% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.5% · Q3 0.5% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.1% |
79.0%
11.1 pts better
|
79.7%
10.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
22.4%
1.4 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 19.5% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-14 · Fire 2024-02-14
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-07 · Fire 2022-12-07
23 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-18
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-18
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-04-14
E · Potential for more than minimal harm
2024-02-14
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 2024-03-12
E · Potential for more than minimal harm
2024-02-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-12
E · Potential for more than minimal harm
2024-02-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-12
F · Potential for more than minimal harm
2022-12-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-08
E · Potential for more than minimal harm
2022-12-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-08
E · Potential for more than minimal harm
2022-12-07
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-03-08
E · Potential for more than minimal harm
2022-12-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-08
D · Potential for more than minimal harm
2022-12-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-08
D · Potential for more than minimal harm
2022-12-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-08
C · Minimal harm
2022-12-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-08
C · Minimal harm
2022-12-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-03-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-03-18
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-03-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-21
G · Actual harm
2024-02-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-14
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-08
D · Potential for more than minimal harm
2023-12-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-17
G · Actual harm
2023-03-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-31
E · Potential for more than minimal harm
2022-12-07
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 2022-12-29
E · Potential for more than minimal harm
2022-12-07
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 2023-02-04
E · Potential for more than minimal harm
2022-12-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-12-07
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
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 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-02-04
D · Potential for more than minimal harm
2022-12-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-07
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 2022-12-29
D · Potential for more than minimal harm
2022-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-29
Penalties and ownership
What sits behind the stars
$8,824
2024-02-14
Fine
Fine · fine $8,824
Fine
Ownership
Trilogy Property Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bardoczi, Stephen
Operational/Managerial Control · Individual
Braverman, Kelly
Operational/Managerial Control · Individual
Dunkle, Amorette
Operational/Managerial Control · Individual
Lcs Kokomo LLC
Operational/Managerial Control · Organization
Ravindra, Baikadi
Operational/Managerial Control · Individual
Sellers, Daniel
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Kokomo Healthcare Center
Kokomo, IN
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 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
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
Jump out