Inspection Report Summary
The most recent inspection on April 1, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed pattern, with several citations related to resident care issues such as medication management, infection control, and documentation, as well as some Life Safety Code deficiencies involving fire safety and emergency preparedness. Complaint investigations were mostly unsubstantiated, though some were substantiated with deficiencies cited, particularly around care planning, medication orders, and resident rights. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The overall trend suggests some improvement in compliance, with recent complaint investigations showing fewer deficiencies compared to earlier reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
26.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
531% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
85% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 1, 2025
Visit Reason
The inspection was conducted in response to a complaint (IN00459069) regarding the administration of prn medications without proper documentation of indication for use in hospice residents.
Findings
The facility failed to ensure that prn medications, specifically Lorazepam and Morphine Sulfate, were administered with documented indications for use for 1 of 3 hospice residents reviewed. There was no documentation of pain, anxiety, or restlessness prior to medication administration, and no explanation for simultaneous administration of the two medications.
Complaint Details
This citation relates to Complaint IN00459069. The Director of Nursing had no additional information to provide during the interview.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure prn medications were administered with documentation for an indication for use for 1 of 3 hospice residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for hospice: 3
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed during the investigation and had no additional information to provide |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 72
Deficiencies: 0
Apr 1, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00456230.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00456230.
Complaint Details
Complaint IN00456230 - No deficiencies related to the allegations are cited.
Report Facts
Census: 61
Total Capacity: 72
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 17, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00452516 completed on February 18, 2025.
Findings
Spring Mill Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Complaint Details
Investigation of Complaint IN00452516 completed on February 18, 2025; facility found in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 18, 2025
Visit Reason
The inspection was conducted based on a complaint investigation related to failure to implement the admission agreement policy and failure to ensure proper blood sugar monitoring for insulin administration.
Findings
The facility failed to have a resident sign and understand the admission agreement, and failed to ensure blood sugar monitoring was performed to determine insulin needs for a resident, resulting in minimal harm or potential for harm to a few residents.
Complaint Details
This citation relates to Complaint IN00452516.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement the admission policy related to an admission Agreement not explained and signed by a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a resident received blood sugar monitoring to determine if insulin was required (sliding scale). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for admission Agreement implementation: 1
Residents reviewed for unnecessary medications: 3
Missed blood sugar monitoring instances: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Admission's Manager | Indicated resident had not signed the admission Agreement and had not explained the items in the agreement. | |
| Administrator | Indicated the admission Agreement was to be completed for all admissions. | |
| Director of Nursing (DON) | Informed of missed blood sugar monitoring and provided facility policies. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 2
Feb 17, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452202, IN00452516, and IN00453660 at Spring Mill Health Campus.
Findings
The investigation found no deficiencies related to complaints IN00452202 and IN00453660. Federal and State deficiencies related to complaint IN00452516 were cited, specifically regarding failure to implement the admission policy and failure to ensure proper blood sugar monitoring for insulin administration in residents.
Complaint Details
Complaint IN00452202 - No deficiencies related to the allegations are cited. Complaint IN00452516 - Federal/State deficiencies related to the allegations are cited at F757. Complaint IN00453660 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement the admission policy related to an Admission Agreement not explained and signed by a resident admitted to the facility. | SS=D |
| Failure to ensure a resident received blood sugar monitoring to determine if insulin was required (sliding scale) for 1 of 3 residents reviewed for unnecessary medications. | SS=D |
Report Facts
Census: 71
SNF/NF beds: 19
SNF beds: 37
Residential beds: 15
Medicare residents: 25
Medicaid residents: 15
Other residents: 16
Total residents by payor: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alisha Boler | RN BSN RNC | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 26, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Spring Mill Health Campus.
Findings
No health deficiencies were found during the inspection, indicating compliance with applicable standards.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Nov 24, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00444104, IN00444124, and IN00447112) and included a Covid-19 Focused Infection Control Survey.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaints and the Covid-19 Focused Infection Control Survey.
Complaint Details
Complaints IN00444104, IN00444124, and IN00447112 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type: 64
Census Payor Type: 50
SNF/NF beds: 14
SNF beds: 36
Residential beds: 14
Medicare residents: 36
Medicaid residents: 14
Inspection Report
Life Safety
Census: 55
Capacity: 64
Deficiencies: 0
Oct 1, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
Spring Mill Health Campus was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a two-story skilled nursing facility with full sprinkler protection and supervised smoke detection.
Report Facts
Certified beds: 64
Census: 55
Medicare certified beds: 64
Medicaid dually certified beds: 10
Diesel generator capacity: 150
Inspection Report
Routine
Deficiencies: 10
Sep 10, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident rights, care, treatment, medication management, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to honor resident self-determination regarding isolation, inadequate staff knowledge of residents' code status, inaccurate resident assessments, insufficient assistance with activities of daily living, failure to follow physician orders for wound care, improper pressure ulcer care, inadequate care and cleaning of feeding tubes, lack of physician orders for PICC line care, improper medication storage, and failure to maintain a clean and sanitary environment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure a resident's preferences were honored related to allowing the resident to leave their room while in contact isolation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff were knowledgeable regarding the residents' code status for 3 of 5 residents reviewed for advanced directives. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the comprehensive assessment was accurate related to dental status for 1 of 17 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dependent residents received at least 2 baths a week and had their hair washed at least weekly for 2 of 4 residents reviewed for activities of daily living. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure surgical bandages were changed as ordered by the physician for 1 of 2 residents reviewed for skin conditions non-pressure. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident with a pressure ulcer had interventions in place related to not floating their heels when in bed for 1 of 3 residents reviewed for pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a peg tube was cleaned on a daily basis and according to facility policy for 1 of 2 residents reviewed for peg tubes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident's PICC line had Physician's Orders for the care and monitoring of a PICC line for 1 of 1 residents reviewed for PICC lines. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medicated creams and loose pills were stored properly for 1 of 1 resident and 1 of 2 medication carts observed during medication storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the resident's environment was clean and sanitary related to an uncontained bed pan for 1 of 3 units. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administrations: 5
Medication administrations: 2
Wound size: 9
Wound size: 0.8
Medication count: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Mentioned in relation to uncertainty about resident isolation status | |
| CNA 1 | Mentioned in relation to resident isolation and peg tube care | |
| Assistant Director of Nursing | ADON | Interviewed regarding resident isolation, wound care, and medication orders |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including wound care, peg tube care, PICC line orders, medication storage, and environment |
| Social Service Director | SSD | Interviewed regarding residents' code status documentation |
| RN 1 | Mentioned in relation to inability to locate residents' code status | |
| Wound Nurse | Mentioned in relation to wound care and peg tube cleaning | |
| LPN 2 | Observed and interviewed regarding medication cart storage |
Inspection Report
Annual Inspection
Census: 15
Deficiencies: 16
Sep 10, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and the Investigation of Nursing Home Complaints IN00436754 and IN00442676.
Findings
The facility had multiple deficiencies including failure to honor resident preferences related to contact isolation, incomplete knowledge of residents' code status, inaccurate comprehensive assessments, inadequate ADL care, improper wound care, failure to clean PEG tubes, lack of PICC line orders, improper medication storage, uncontained bed pans, failure to notify physicians/families of significant changes, incomplete service plans, incomplete clinical records, and missing annual tuberculosis health statements.
Complaint Details
Complaint IN00436754 - No deficiencies related to the allegations are cited. Complaint IN00442676 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 11
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure a resident's preferences were honored related to allowing the resident to leave their room while in contact isolation. | SS=D |
| Failed to ensure staff were knowledgeable regarding the residents' code status for 3 of 5 residents reviewed for advanced directives. | SS=D |
| Failed to ensure the comprehensive assessment was accurate related to dental status for 1 of 17 residents reviewed. | SS=D |
| Failed to ensure dependent residents received at least 2 baths a week and had their hair washed at least weekly for 2 of 4 residents reviewed. | SS=D |
| Failed to ensure surgical bandages were changed as ordered by the physician for 1 of 2 residents reviewed for skin conditions non-pressure. | SS=D |
| Failed to ensure a resident with a pressure ulcer had interventions in place related to not floating their heels when in bed for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure a peg tube was cleaned on a daily basis and according to facility policy for 1 of 2 residents reviewed for peg tubes. | SS=D |
| Failed to ensure a resident's PICC line had Physician's Orders for the care and monitoring of a PICC line for 1 of 1 residents reviewed. | SS=D |
| Failed to ensure a PRN psychotropic medication was not ordered longer than 14 days for 1 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to store medicated creams and loose pills properly for 1 of 1 resident and 1 of 2 medication carts observed during medication storage. | SS=D |
| Failed to ensure the resident's environment was clean and sanitary related to an uncontained bed pan for 1 of 3 units. | SS=D |
| Failed to promptly notify the resident's physician and/or family of significant changes in status related to high blood sugar levels and a fall for 2 of 7 residents reviewed. | — |
| Failed to ensure resident service plans were updated and/or signed by the resident or representative for 2 of 7 service plans reviewed. | — |
| Failed to ensure the clinical record was complete and accurately documented related to blood pressure medications administered outside of parameters, blanks on medication administration records, and the lack of documentation for Foley catheter care for 2 of 7 residents reviewed. | — |
| Failed to ensure an annual health statement was obtained which indicated the residents showed no evidence of tuberculosis in an infectious stage for 5 of 7 resident records reviewed. | — |
| Failed to ensure a resident had an annual tuberculin (TB) assessment for 1 of 7 residents reviewed for TB test or screenings. | — |
Report Facts
Survey dates: 6
Census: 15
Medication administrations: 5
Medication administrations: 2
Audit frequency: 5
Audit frequency: 3
Audit frequency: 2
Audit frequency: 3
Audit frequency: 3
Audit frequency: 3
Audit frequency: 3
Audit frequency: 5
Audit frequency: 2
Audit frequency: 3
Audit frequency: 5
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lakeithia Webb | Executive Director | Signed the report on 09/27/2024 |
Inspection Report
Renewal
Deficiencies: 0
Sep 10, 2024
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on September 10, 2024.
Findings
Spring Mill Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Jun 11, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home and Residential Complaints IN00429911, IN00432277, and Nursing Home Complaint IN00434296.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00429911 - No deficiencies related to the allegations are cited. Complaint IN00432277 - No deficiencies related to the allegations are cited. Complaint IN00434296 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF/NF: 57
Census Bed Type - Residential: 19
Total Census: 76
Census Payor Type - Medicare: 24
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 15
Total Census Payor: 57
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 13, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00419120, IN00423550, and IN00427249 completed on February 20, 2024.
Findings
Spring Mill Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the complaint investigation.
Complaint Details
The document relates to complaint investigations IN00419120, IN00423550, and IN00427249 with a paper compliance review completed.
Report Facts
Complaint investigation IDs: IN00419120, IN00423550, IN00427249
Inspection Report
Complaint Investigation
Deficiencies: 6
Feb 20, 2024
Visit Reason
The inspection was conducted in response to complaints regarding failure to provide appropriate wound care, feeding tube care, medication administration, supervision, and infection control at Spring Mill Health Campus.
Findings
The facility failed to ensure proper treatment and care for residents with skin conditions, feeding tubes, and infections, including incomplete wound care, improper medication administration, inadequate supervision, and lapses in infection control practices such as cleaning reusable equipment and hand hygiene.
Complaint Details
The inspection relates to Complaints IN00427249, IN00423550, IN00419120, and IN00427249 involving issues with wound care, feeding tube care, medication administration, supervision, and infection control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure bandages were changed and treatments completed as ordered for a diabetic ulcer and a non-pressure ulcer for 1 of 3 residents reviewed for skin conditions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident with pressure ulcers received necessary care and treatment to promote healing, including treatments not completed as ordered and bandages not secure and in place. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure gastrostomy enteral feedings were infusing at the correct time, tubing was changed at least every 24 hours, stoma sites were cleaned as ordered, and medications were administered per facility policy for 3 residents with peg tubes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to manage medications appropriately, including not administering antibiotic and pain medication as ordered for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure clinical records were complete related to the determination to discontinue 15 minute checks for a resident who was observed with an unlit cigarette. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection control guidelines were implemented related to cleaning of reusable equipment and hand hygiene after direct resident contact and glove removal. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 6
Medication doses: 4
Medication administration times missed: 2
Treatment dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Interviewed regarding bandage changes and infection control practices | |
| Wound Care Nurse | Interviewed regarding bandage change frequency and pressure ulcer care | |
| Director of Nursing | Director of Nursing | Interviewed regarding antibiotic administration, feeding tube care, infection control, and pain medication administration |
| LPN 1 | Observed and interviewed regarding peg tube medication administration | |
| RN 2 | Observed and interviewed regarding blood pressure cuff cleaning and medication administration | |
| Nurse Consultant | Provided in-service training on peg tube medication administration | |
| Administrator | Administrator | Interviewed regarding discontinuation of 15 minute checks for Resident K |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 85
Deficiencies: 6
Feb 19, 2024
Visit Reason
This visit was for the investigation of nursing home complaints IN00419120, IN00423550, IN00427249, and residential complaint IN00418622.
Findings
The facility was cited for multiple deficiencies related to quality of care, treatment of pressure ulcers, tube feeding management, drug regimen, resident records, and infection prevention and control. Some residents did not receive treatments or medications as ordered, reusable equipment was not cleaned properly, and clinical records were incomplete regarding supervision checks.
Complaint Details
Complaint IN00418622 - No deficiencies related to the allegations are cited. Complaint IN00419120 - Deficiencies cited at F757. Complaint IN00423550 - Deficiencies cited at F693 and F842. Complaint IN00427249 - Deficiencies cited at F684, F686, and F757.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure bandages were changed and treatments completed as ordered for a diabetic ulcer and non-pressure ulcer (Resident P). | SS=D |
| Failed to ensure a resident with pressure ulcers received necessary care and treatment to promote healing; treatments not completed as ordered and bandages not secure (Resident O). | SS=D |
| Failed to ensure gastrostomy enteral feedings were infused at correct times, tubing changed every 24 hours, stoma sites cleaned as ordered, and medications administered per policy (Residents L, D, M). | SS=D |
| Failed to manage medications appropriately; antibiotic and pain medications not administered as ordered (Residents B, P, L). | SS=D |
| Failed to maintain complete clinical records related to discontinuation of 15-minute checks for a resident observed with an unlit cigarette (Resident K). | SS=D |
| Failed to ensure infection control guidelines were followed; reusable equipment not cleaned between residents and hand hygiene not performed after glove removal (Residents P, D, R, S). | SS=E |
Report Facts
Census: 26
Total Capacity: 85
Deficiencies cited: 6
Survey dates: 2024-02-19 to 2024-02-20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lakeithia Webb | Executive Director | Signed report cover page |
| RN 1 | Named in findings related to wound care and infection control observations | |
| LPN 1 | Named in findings related to tube feeding medication administration | |
| RN 2 | Named in findings related to blood pressure cuff cleaning and medication administration | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and corrective actions |
| Nurse Consultant | Provided inservice to LPN 1 on tube feeding medication administration |
Inspection Report
Re-Inspection
Census: 44
Capacity: 64
Deficiencies: 1
Oct 23, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/24/23 was performed to verify correction of previous deficiencies related to generator maintenance and testing.
Findings
The facility was found in substantial compliance with Life Safety Code requirements. However, a deficiency was cited for failure to document the actual load percentage during monthly generator exercises for 12 of 12 months, which could affect all occupants. The facility implemented a plan of correction including updated documentation and staff re-education.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to exercise the generator for 12 of 12 months with documented load percentage as required by NFPA 110, 2010 Edition. | SS=C |
Report Facts
Facility capacity: 64
Census: 44
Beds dually certified for Medicaid: 10
Generator exercise frequency: 12
Generator exercise duration: 30
Generator exercise interval: 20
Generator extended exercise duration: 240
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lakeithia Webb | Executive Director | Participated in review of generator load testing documentation and exit conference |
| Maintenance Director | Interviewed regarding generator testing and documentation; re-educated on documentation procedures | |
| VP of Regional Operations | Participated in exit conference discussing deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 19, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00417366) regarding the facility's failure to ensure a Physician's Order was in place for a resident receiving oxygen therapy.
Findings
The facility failed to have a Physician's Order documented for oxygen therapy for Resident G, who was observed receiving oxygen at 3 liters via nasal cannula. The Director of Nursing confirmed the order was entered late, on 9/19/23, and should have been in place at admission.
Complaint Details
This Federal tag relates to Complaint IN00417366.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a Physician's Order was in place for a resident receiving oxygen therapy. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Oxygen flow rate: 3
Oxygen flow rate: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding the oxygen order for Resident G and observed removing the oxygen tank. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 19, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00417366 completed on September 19, 2023.
Findings
Spring Mill Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Complaint Details
Investigation of Complaint IN00417366; paper compliance review completed with findings of compliance.
Inspection Report
Complaint Investigation
Census: 48
Capacity: 77
Deficiencies: 1
Sep 18, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00417122, IN00417317, and IN00417366. Complaints IN00417122 and IN00417317 had no deficiencies cited, while complaint IN00417366 resulted in federal/state deficiencies related to respiratory/tracheostomy care.
Findings
The facility failed to ensure a Physician's Order was in place for a resident (Resident G) who received oxygen therapy. The resident was observed receiving oxygen without a documented order until one was obtained on 9/19/23. The facility implemented corrective actions including staff re-education and ongoing audits to prevent recurrence.
Complaint Details
Complaint IN00417122 and IN00417317 had no deficiencies related to the allegations. Complaint IN00417366 was substantiated with federal/state deficiencies cited at F695 related to respiratory/tracheostomy care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a Physician's Order was in place for a resident receiving oxygen therapy. | SS=D |
Report Facts
Census: 48
Total Capacity: 77
Deficiencies cited: 1
Oxygen flow rate: 3
Oxygen flow rate: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lakeithia Webb | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding oxygen order for Resident G; name not fully provided |
Inspection Report
Life Safety
Census: 54
Capacity: 64
Deficiencies: 6
Aug 24, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 08/24/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain latching hardware on smoke barrier doors, stairway enclosure doors not latching properly, incomplete fire alarm system inspection, missing sprinkler system quarterly inspection documentation, overdue internal pipe inspection, failure to document generator cool down time and transfer times, and use of multi-plug adaptors in a Social Services office.
Severity Breakdown
SS=E: 3
SS=F: 2
SS=C: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain latching hardware on 1 of 5 smoke barrier doors, affecting approximately 10 residents and staff. | SS=E |
| Failed to ensure 1 of 4 stairway enclosure doors latched properly, affecting approximately 10 residents and staff. | SS=E |
| Failed to ensure 1 of 1 fire alarm systems was maintained and inspected properly; two duct detectors were not inspected. | SS=F |
| Failed to provide documentation of sprinkler system inspection for 1 of 4 quarters and overdue internal pipe inspection. | SS=F |
| Failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after load test and failed to document load percentages and transfer times. | SS=C |
| Failed to ensure 1 of 1 Social Services office did not use multi-plug adaptors as a substitute for fixed wiring. | SS=E |
Report Facts
Certified beds: 64
Census: 54
Deficiencies cited: 6
Date of compliance: Sep 8, 2023
Date of compliance: Oct 20, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lakeithia Webb | Executive Director | Signed the report |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 16
Aug 11, 2023
Visit Reason
This visit was for a State Residential Licensure Survey and included the Investigation of Residential Complaint IN00414473.
Findings
The facility was found deficient in multiple areas including failure to ensure proper medication self-administration orders, assistance with activities of daily living, fall follow-up and neurological checks, pressure ulcer treatment, range of motion care, respiratory care, medication administration timing, laboratory services, infection prevention and control, antibiotic stewardship, environmental sanitation, resident rights notification, service plan signatures, and clinical record completeness.
Complaint Details
Complaint IN00414473 - State deficiencies related to the allegations are cited at R0036 and R0349. Complaint IN00413735 and IN00413771 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 10
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure residents had Physician's Orders and assessments for self-administration of medications. | SS=D |
| Failed to ensure dependent residents received assistance with ADLs including bathing, nail care, shaving, and clean clothing and linens. | SS=D |
| Failed to ensure fall follow-ups and neurological checks were initiated and/or completed following a fall. | SS=D |
| Failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing and prevent infection. | SS=D |
| Failed to ensure contractures were identified, treated, monitored, and splints applied as ordered. | SS=D |
| Failed to ensure oxygen was administered at the correct flow rate. | SS=D |
| Failed to ensure residents were free of significant medication errors related to timing of insulin administration. | SS=D |
| Failed to ensure specimens for laboratory testing were collected as ordered and results promptly notified to physician. | SS=D |
| Failed to ensure infection control guidelines were implemented including proper cleaning of reusable equipment, hand hygiene, and proper disposal of lancets. | SS=D |
| Failed to promote antibiotic stewardship by ensuring appropriate use of antibiotic therapy and obtaining cultures prior to antibiotics. | SS=D |
| Failed to provide a clean, orderly, and well-maintained environment including repair of ripped carpet, removal of urine odor, and cleaning of stained carpets and rusted door frames. | SS=D |
| Failed to ensure fire drills were conducted in conjunction with the local fire department at least every 6 months. | — |
| Failed to ensure service plans were signed by residents or their representatives and updated according to changes in condition. | — |
| Failed to ensure clinical records were complete and accurate related to fall follow-up assessments, neurological checks, PRN medication use, and medication administration documentation. | — |
| Failed to ensure residents were offered influenza and pneumococcal vaccinations and documentation of offers was maintained. | — |
| Failed to ensure hand hygiene was performed before donning and after doffing gloves during medication pass. | — |
Report Facts
Census: 34
Deficiency count: 15
Fall follow up assessments: 4
Neurological checks: 72
Insulin units: 30
Antibiotic doses: 10
Handwashing audit frequency: 3
Handwashing audit duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lakeithia Webb | Executive Director | Signed report cover page |
Inspection Report
Renewal
Deficiencies: 0
Aug 11, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on August 11, 2023.
Findings
Spring Mill Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Routine
Deficiencies: 11
Aug 11, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including medication administration, resident care, infection control, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to ensure proper medication self-administration orders, inadequate assistance with activities of daily living, incomplete fall follow-ups and neurological checks, insufficient pressure ulcer care, lack of contracture treatment and monitoring, incorrect oxygen administration, medication timing errors, failure to obtain ordered laboratory tests, improper infection control practices, and inadequate antibiotic stewardship. Environmental concerns included urine odor and carpet damage in resident areas.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure residents had Physician's Orders and assessment for self-administration of medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dependent residents received assistance with activities of daily living including bathing, nail care, shaving, and clean clothing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure fall follow-ups and neurological checks were initiated and/or completed following a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing; treatments not completed as ordered and treatment orders not updated timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure contractures were identified, treated, and monitored, and splints were applied as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure oxygen was administered at the correct flow rate. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from significant medication errors related to timing of insulin administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure specimens for laboratory testing were collected as ordered by the Physician. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection control guidelines were implemented including proper cleaning of reusable equipment, hand hygiene between glove use, and proper disposal of lancets. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to promote antibiotic stewardship by ensuring appropriate use of antibiotic therapy and obtaining cultures prior to antibiotic use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the residents' environment was clean and in good repair related to urine odor and ripped carpet on 2 of 3 units. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 11
Insulin late administration dates: 7
Medication administration flow rate: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Observed during medication pass with improper hand hygiene and disposal of lancet related to infection control deficiency |
| Director of Nursing | Interviewed multiple times regarding deficiencies including medication orders, fall follow-ups, wound care, oxygen administration, insulin timing, laboratory draws, and antibiotic stewardship | |
| RN 1 | Registered Nurse | Noted contractures in Resident 37 and indicated need for therapy assessment |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding splinting device use for Resident 212 |
| Nurse Consultant | Interviewed regarding infection control practices | |
| Administrator | Interviewed regarding contracture assessment and therapy referral | |
| Director of Maintenance | Interviewed regarding environmental concerns of urine odor and carpet damage | |
| Housekeeping Supervisor | Interviewed regarding environmental concerns of urine odor and carpet damage |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 21, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00410811 completed on June 21, 2023.
Findings
Spring Mill Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Complaint Details
Investigation of Complaint IN00410811 completed with findings of compliance.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jun 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about honoring residents' advance directives and proper insulin administration.
Findings
The facility failed to honor a resident's code status preference regarding DNR orders and failed to ensure proper insulin administration for another resident, resulting in actual harm. The facility had policies in place but did not fully implement them, leading to inappropriate CPR initiation and insulin overdose.
Complaint Details
This Federal tag relates to Complaint IN00410811.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Actual harm: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to implement advance directives and ensure a resident's code status preference was honored for 1 of 3 residents reviewed for hospitalization. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident received the necessary treatment and services related to insulin administration for 1 of 3 residents reviewed for insulin administration. | Level of Harm - Actual harm |
| Failed to confirm and process physician's orders properly following a physician visit. | Level of Harm - Actual harm |
Report Facts
Residents reviewed for hospitalization: 3
Residents reviewed for insulin administration: 3
Insulin doses given incorrectly: 6
Date of deficient practice correction: Jun 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding CPR initiation and code status | |
| Director of Nursing | Interviewed regarding CPR initiation, insulin administration errors, and physician order confirmation |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Jun 20, 2023
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00410811 and Residential Complaint IN00399688.
Findings
Complaint IN00410811 resulted in Federal/State deficiencies cited at F578 and F684 related to failure to implement advance directives and ensure a resident's code status preference was honored. Complaint IN00399688 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00410811 was substantiated with deficiencies cited. Complaint IN00399688 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to implement advance directives and ensure a resident's code status preference was honored for 1 of 3 residents reviewed for hospitalization (Resident C). | SS=D |
Report Facts
Census Bed Type Total: 83
Census Payor Type Total: 48
SNF beds: 32
NF beds: 16
Residential beds: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lakeithia Webb | Executive Director | Signed report and involved in interview regarding findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 13, 2023
Visit Reason
Paper compliance review to the investigation of complaints IN00384204, IN00386749, IN00391758, and IN00393305 completed on November 30, 2022.
Findings
Spring Mill Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the complaint investigation.
Complaint Details
Paper compliance review related to complaints IN00384204, IN00386749, IN00391758, and IN00393305; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 50
Capacity: 85
Deficiencies: 8
Nov 28, 2022
Visit Reason
This visit was for the investigation of multiple complaints (IN00384204, IN00386749, IN00391758, and IN00393305) regarding alleged deficiencies at Spring Mill Health Campus.
Findings
The facility was found to have multiple deficiencies including failure to ensure proper medication self-administration assessments, misappropriation of controlled medications, incomplete implementation of care plans, inadequate ADL care, unsafe transfer practices, improper PICC line care, failure to administer oxygen as ordered, and inaccurate controlled drug reconciliation.
Complaint Details
This visit was triggered by complaints IN00384204, IN00386749, IN00391758, and IN00393305. All complaints were substantiated with related federal/state deficiencies cited.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure a resident had a Physician's Order and assessment to self-administer medications. | SS=D |
| Failed to ensure residents were free from misappropriation of resident property related to missing narcotic/controlled medication and failed to report incidents timely. | SS=D |
| Failed to ensure residents' plans of care were implemented related to medication administration. | SS=D |
| Failed to ensure residents requiring extensive to total care with ADLs were provided necessary services to maintain good grooming and personal hygiene. | SS=D |
| Failed to ensure interventions were in place and safe transfers were performed to prevent falls/accidents and injuries. | SS=D |
| Failed to care for PICC lines in accordance with professional standards, including lack of assessments, measurements, and dressing changes. | SS=D |
| Failed to ensure oxygen was administered to residents as ordered by the Physician. | SS=D |
| Failed to ensure records of receipt and disposition of controlled drugs had accurate reconciliation at the start and end of every shift. | SS=E |
Report Facts
Census: 50
Total Capacity: 85
Deficiencies cited: 8
Narcotic count audit frequency: 5
Narcotic count audit duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mehay | Facility Representative | Signed plan of correction letter |
| Rosa McGowen | Regional Director of Operations | Signed report |
Inspection Report
Re-Inspection
Census: 62
Capacity: 100
Deficiencies: 0
Aug 10, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the Investigation of Complaint IN00375538 completed on June 27, 2022.
Findings
Spring Mill Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00375538.
Complaint Details
Complaint IN00375538 was investigated and found to be corrected.
Report Facts
Census Bed Type: 100
Census Payor Type: 62
Inspection Report
Life Safety
Census: 62
Capacity: 64
Deficiencies: 1
Aug 2, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Specifically, the facility failed to ensure that corridor doors to three hazardous areas (combustible storage rooms, soiled linen rooms, and boiler rooms) were equipped with self-closing devices or smoke resistant partitions, potentially affecting 18 residents, 4 staff, and 2 visitors.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure corridor doors to 3 of 7 hazardous areas had self-closing devices or smoke resistant partitions, affecting combustible storage rooms, soiled linen rooms, and boiler rooms. | SS=E |
Report Facts
Certified beds: 64
Census: 62
Dually certified beds: 10
Residents potentially affected: 18
Staff potentially affected: 4
Visitors potentially affected: 2
Facility office size: 360
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mehay | Executive Director | Named in plan of correction and correspondence |
Inspection Report
Life Safety
Deficiencies: 0
Aug 2, 2022
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 08/02/22.
Findings
Spring Mill Health Campus was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Deficiencies: 14
Jun 27, 2022
Visit Reason
The inspection was conducted based on complaints and concerns related to resident care, medication management, infection control, and behavioral health services at Spring Mill Health Campus.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, improper call light accessibility, medication administration errors, inadequate assistance with activities of daily living, insufficient skin care and treatment, failure to follow dietary recommendations, improper oxygen administration, inadequate pain management, lack of dialysis post-assessment, failure to follow up on behavioral health referrals, improper medication storage, and lapses in infection control practices.
Complaint Details
The investigation was complaint-driven, addressing multiple concerns including resident dignity, medication errors, infection control, and behavioral health follow-up.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure a resident's dignity was maintained related to not placing a dignity bag over a foley catheter drainage bag. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure call lights were in reach for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were not borrowed from another resident for medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dependent residents received assistance with activities of daily living related to nail care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure areas of bruising, abrasions, and foot discoloration were assessed and monitored and treatments completed and signed as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents' diets were followed as ordered and recommended by speech therapy and Registered Dietitian. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure oxygen was administered at the correct flow rate and time for residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure each resident was free from pain related to a resident exhibiting signs and symptoms of pain with no relief. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a post dialysis assessment was completed at the time of return from hemodialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents' blood pressure and pulse were monitored prior to administration of antihypertensive medications and orders were received to hold medication as well as indications for Tylenol use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a psychotropic medication was not ordered prn longer than 14 days. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were stored properly and with appropriate labeling in medication rooms and carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection control guidelines were implemented including glove use, N95 mask use, proper storage of bed pans and wash basins, COVID-19 monitoring, lancet disposal, and glucometer sanitation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure COVID-19 monitoring was completed at required frequency for residents in isolation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for call light issue: 15
Residents reviewed for medication borrowing: 6
Residents reviewed for ADL assistance: 5
Residents reviewed for skin care: 5
Residents reviewed for nutrition: 3
Residents reviewed for oxygen use: 5
Residents reviewed for pain management: 1
Residents reviewed for dialysis care: 1
Residents reviewed for unnecessary medications: 5
Residents reviewed for psychotropic medication use: 5
Medication administration dates missed: 9
Medication administration dates missed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Observed administering medications incorrectly and interviewed regarding medication errors and oxygen administration. | |
| Director of Nursing | Interviewed multiple times regarding deficiencies in care, medication administration, infection control, and follow-up. | |
| Nurse Consultant | Interviewed regarding medication errors, infection control, and care deficiencies. | |
| Assistant Director of Nursing | Observed providing care and interviewed regarding wound care and medication administration. | |
| QMA 1 | Observed performing blood sugar checks and interviewed regarding infection control lapses. | |
| CNA 1 | Observed with infection control lapses including glove and mask use. | |
| CNA 2 | Observed with infection control lapses including glove and mask use. | |
| LPN 1 | Interviewed regarding medication cart storage. |
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