Inspection Reports for Friends Fellowship Community
2030 CHESTER BLVD, RICHMOND, IN, 47374
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 13, 2025, found Friends Fellowship Community in compliance with fire safety and licensure requirements and noted no deficiencies. Earlier inspections showed a mixed pattern, with some Life Safety Code deficiencies related to fire wall maintenance, corridor door closures, fire alarm inspections, and medication management issues. Prior reports cited problems such as propped open doors, incomplete fire drill documentation, and a staff member working with an expired CNA certification, but no fines or enforcement actions were listed in the available reports. Complaint investigations were unsubstantiated, with no deficiencies found related to the allegations. The trend suggests improvement in fire safety compliance following earlier citations, with the most recent surveys showing no outstanding issues.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
40% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Original Licensing
Census: 37
Capacity: 92
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
A Preoccupancy Survey for State Licensure was conducted by the Indiana Department of Health for the relocation of 24 NCC beds from rooms 10-28 and 40-44 to rooms 70-81 in Courtyard I.
Findings
At this Preoccupancy survey, Friends Fellowship Community was found in compliance with the Requirements of the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinkled with a fire alarm system and smoke detection throughout.
Report Facts
Beds relocated: 24
Inspection Report
Re-Inspection
Census: 35
Capacity: 92
Deficiencies: 0
Date: Mar 26, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the PSR from 01/21/25 and the Life Safety Code State Licensure Survey conducted on 11/26/24 by the Indiana State Department of Health.
Findings
At this PSR survey, Friends Fellowship Community was found in compliance with the Requirements of the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinkled with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 92
Census: 35
Inspection Report
Re-Inspection
Census: 57
Capacity: 92
Deficiencies: 3
Date: Jan 21, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code State Licensure Survey conducted on 11/26/2024 was conducted to verify correction of previous deficiencies.
Findings
The facility was found not in compliance with the 2000 edition of the NFPA 101 Life Safety Code and 410 IAC 16.2. Deficiencies included failure to maintain the construction type with holes in the draft stop wall, a corridor door propped open impairing closure, and failure to maintain semi-annual fire alarm system inspections. Plans of correction were submitted for each deficiency.
Deficiencies (3)
Failure to maintain the draft stop wall above the corridor door by Room 41, with numerous holes noted in the drywall impairing smoke and heat resistance.
Corridor door to resident sleeping Room 72 was propped open with a trash can, impeding proper closing and latching.
Failure to maintain semi-annual visual inspections of the fire alarm system as required by NFPA 72.
Report Facts
Facility capacity: 92
Census: 57
Resident rooms affected: 1
Date of original survey: Nov 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Rees | Executive Director | Signed the report |
| Maintenance Director | Interviewed and involved in observations related to deficiencies |
Inspection Report
Life Safety
Census: 46
Capacity: 92
Deficiencies: 10
Date: Nov 26, 2024
Visit Reason
A Life Safety Code State Licensure Survey was conducted by the Indiana Department of Health to assess compliance with the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Findings
The facility was found not in compliance with several Life Safety Code standards including failure to maintain the required 2-hour fire wall, impediments to corridor door closures, inadequate separation of hazardous areas, lack of posted door codes for exit doors, obstructions in means of egress, incomplete fire drill documentation, improper smoke detector placement, lack of semi-annual fire alarm inspections, outdated fire extinguisher maintenance, and unlabeled remote manual stop for the emergency generator.
Deficiencies (10)
Failed to maintain the 2-hour fire wall in the Healthcare Center attic above the corridor door by Room 41; drywall only mounted on one side and holes present.
Corridor doors to resident sleeping Rooms 33 and 72 were propped open, impeding proper closing and latching.
Failed to ensure 1 of 7 hazardous areas such as soiled linen rooms were separated by smoke resistant partitions and doors.
Means of egress through 2 of 6 exits were not readily accessible; exit door codes were not posted at keypad.
Means of egress for 1 of 6 exits was obstructed by a stand up Hoyer lift and a Hoyer lift extending 30 inches into the corridor.
Fire drill documentation did not include staff participation and response for all shifts in the most recent 12 months.
Smoke detector outside oxygen storage and transfilling room was improperly located 18 inches from an air supply vent, preventing proper operation.
Failed to maintain fire alarm system with required visual semi-annual inspections; documentation for six months after 02/12/24 was not available.
One portable fire extinguisher had not undergone required 12-year hydrostatic testing; last 6-year maintenance was in August 2018.
Remote manual stop for emergency generator was not labeled as required by NFPA 99.
Report Facts
Facility capacity: 92
Census: 46
Resident rooms with smoke detectors: 24
Resident rooms with smoke detectors: 35
Fire drill quarters missing documentation: 4
Fire alarm inspection date: Feb 12, 2024
Fire extinguisher maintenance date: 201808
Fire extinguisher maintenance date: 201608
Fire extinguisher annual maintenance date: 202408
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Rees | Interim Executive Director | Signed the report and participated in exit conference |
| Maintenance Director | Interviewed and acknowledged deficiencies related to fire wall, door closures, smoke detector placement, fire alarm inspections, fire extinguisher maintenance, and emergency generator labeling |
Inspection Report
Renewal
Census: 108
Capacity: 146
Deficiencies: 2
Date: Oct 21, 2024
Visit Reason
This visit was for a Residential Licensure Survey which included a State Licensure Survey conducted on October 16, 17, 18, and 21, 2024.
Findings
The facility was found deficient in assuring effectiveness of as needed medications and obtaining ordered blood pressures and weights for residents. Additionally, a staff member was found to have worked with an expired Certified Nursing Assistant certification. The facility implemented corrective actions including policy reviews, staff education, and monitoring systems to ensure compliance.
Deficiencies (2)
Failed to reassure effectiveness for as needed medications and failed to obtain blood pressures and weights as ordered for 2 of 8 residents reviewed.
Failed to ensure a staff member maintained an active Certified Nursing Assistant (CNA) certification; CNA worked after certification expired.
Report Facts
Residential Census: 108
Total Capacity: 146
Hours worked post certification expiration: 51.3
Survey Dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Harrison | Director of Nursing | Interviewed regarding deficiencies and corrective actions; signed report |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: May 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00421924 at Friends Fellowship Community.
Complaint Details
Complaint IN00421924 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00421924 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Report Facts
Residential Census: 93
NCC Census: 38
Total Census: 131
Inspection Report
Renewal
Census: 126
Capacity: 126
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
This visit was for a State Licensure Survey including a Residential Licensure Survey conducted on August 14 and 15, 2023.
Findings
Friends Fellowship Community was found to be in compliance with 410 IAC 16.2-3.1 and 410 IAC 16.2-5 in regard to the State Licensure and Residential Licensure Surveys.
Report Facts
Census bed type - NCC: 37
Census bed type - Residential: 89
Total census: 126
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