Deficiencies per Year
8
6
4
2
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
May 28, 2025
Visit Reason
The visit was conducted to investigate complaints IN00455338, IN00458980, and IN00459493 regarding the facility's compliance with regulations.
Findings
No deficiencies were found related to complaints IN00455338 and IN00459493. Deficiencies related to complaint IN00458980 were cited involving failure to use a gait belt during resident transfer, resulting in a fall with injury. The deficient practice was corrected prior to the survey.
Complaint Details
Complaint IN00455338 had no deficiencies related to allegations. Complaint IN00458980 had federal/state deficiencies cited related to allegations. Complaint IN00459493 had no deficiencies related to allegations.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a staff member used a gait belt during a transfer, resulting in a resident fall with abrasion and femur fracture. | SS=G |
Report Facts
Census: 83
SNF/NF beds: 76
SNF beds: 7
Medicare residents: 7
Medicaid residents: 61
Other payor residents: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Named in deficiency for failure to use gait belt during transfer resulting in resident fall |
| Director of Nursing | Interviewed regarding gait belt policy and deficiency | |
| Director of Therapy | Interviewed regarding therapy evaluation and gait belt use | |
| CNA 3 | Certified Nursing Assistant | Interviewed regarding gait belt use |
| RN 4 | Registered Nurse | Interviewed regarding gait belt use |
| CNA 5 | Certified Nursing Assistant | Interviewed regarding gait belt use |
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Mar 24, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00451659 completed on February 11, 2025.
Findings
Spring Mill Meadows 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 Investigation of Complaint IN00451659. The complaint was corrected.
Complaint Details
Complaint IN00451659 - Corrected.
Report Facts
Census: 95
SNF beds: 10
SNF/NF beds: 85
Medicare residents: 8
Medicaid residents: 63
Other payor residents: 24
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Feb 11, 2025
Visit Reason
This visit was for the investigation of Complaint IN00451659 regarding federal and state deficiencies related to allegations of inadequate quality of care.
Findings
The facility failed to ensure a resident with metastatic prostate cancer received ordered cancer medications, had timely follow-up oncology appointments, and the medical director discontinued a high-cost cancer medication without consulting the oncologist, resulting in delayed oncology care and progression of the resident's cancer.
Complaint Details
Complaint IN00451659 was substantiated with federal and state deficiencies cited at F684 related to quality of care issues for Resident B involving cancer medication and follow-up care.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident received ordered cancer medication and follow-up oncology care, and medical director discontinued medication without oncologist consultation. | SS=G |
Report Facts
Census: 92
SNF beds: 10
SNF/NF beds: 82
Medicare residents: 11
Medicaid residents: 54
Other payor residents: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding resident's chemotherapy drug orders and follow-up care |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Dec 6, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00444210 and IN00447986, regarding the facility.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00444210 and Complaint IN00447986 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 92
SNF beds: 9
SNF/NF beds: 83
Medicare residents: 8
Medicaid residents: 56
Other payor residents: 28
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 2, 2024
Visit Reason
Paper compliance review for the Recertification and State Licensure Survey and the Investigation of Complaint IN00439059 completed on August 28, 2024.
Findings
Spring Mill Meadows 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 and the Investigation of Complaint IN00439059.
Complaint Details
Investigation of Complaint IN00439059 completed on August 28, 2024; facility found in compliance.
Inspection Report
Annual Inspection
Census: 84
Capacity: 130
Deficiencies: 1
Sep 16, 2024
Visit Reason
The inspection was conducted as an annual Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements due to one set of smoke barrier doors failing to restrict smoke movement for at least 20 minutes. The doors did not close completely or latch, leaving a one-inch gap, potentially affecting residents, staff, and visitors.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes; doors did not close completely or latch, leaving a one-inch gap. | SS=E |
Report Facts
Certified beds: 130
Census: 84
Sets of smoke barrier doors: 6
Residents potentially affected: 12
Staff potentially affected: 4
Visitors potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Kump-Tarbutton | Executive Director | Signed the report |
| Director of Maintenance | Acknowledged smoke barrier doors did not close completely or latch and responsible for corrective actions | |
| Field Maintenance Supervisor | Present during observation of deficient smoke barrier doors |
Inspection Report
Life Safety
Deficiencies: 0
Sep 16, 2024
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and licensure requirements.
Findings
Spring Mill Meadows was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 82
Capacity: 82
Deficiencies: 7
Aug 28, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of multiple complaints.
Findings
The facility was cited for deficiencies related to discharge planning, quality of care including medication administration and physician notification, accident prevention, psychotropic medication management, medication storage, dental services, and food safety. Some deficiencies were corrected prior to the survey, while others required plans of correction.
Complaint Details
This survey included investigation of complaints IN00429846, IN00435561, IN00439059, IN00439436, and IN00440642. Deficiencies related to complaints IN00429846, IN00435561, and IN00439059 were cited. Complaints IN00439436 and IN00440642 had no deficiencies cited.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure a facility arranged transfer included the correct address for 1 resident (Resident F). | SS=D |
| Failed to ensure physician notification and medication administration according to ordered parameters for 5 residents. | SS=E |
| Failed to ensure physical therapy recommended transfer method was used for 1 resident (Resident E). | SS=D |
| Failed to complete abnormal involuntary movement scale (AIMS) assessment and provide black box warning education for 1 resident on antipsychotic medication (Resident 37). | SS=D |
| Failed to ensure medication carts were free of loose medications, inhalers labeled, narcotic cards free of compromise, and narcotic count logs accurate. | SS=D |
| Failed to assist a resident to obtain dentures as recommended during dental exam (Resident 20). | SS=D |
| Failed to ensure frozen foods were sealed and free of moisture in the walk-in freezer. | SS=D |
Report Facts
Survey dates: August 21, 22, 23, 26, 27, 28, 2024
Census: 82
Total Capacity: 82
Residents reviewed for quality of care: 5
Residents reviewed for dental services: 3
Medication carts reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Tarbutton | Executive Director | Signed the report |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and policies |
| Director of Therapy | Director of Therapy | Interviewed regarding transfer recommendations and documentation |
| Social Services Assistant | Social Services Assistant | Interviewed regarding discharge planning and dental services |
| Business Office Manager | Business Office Manager | Provided statement regarding transport company incident |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding medication cart and narcotic reconciliation |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding medication cart and destruction of loose pills |
| Unit Manager | Unit Manager | Interviewed regarding narcotic card procedures |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding freezer defrosting |
| Dietary Manager | Dietary Manager | Interviewed regarding freezer condition and food storage |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Feb 1, 2024
Visit Reason
The visit was conducted for the investigation of complaints IN00425041, IN00425093, and IN00425240 regarding allegations of misappropriation of resident property.
Findings
The facility failed to ensure residents' credit cards were kept safe and secure during admission for 2 of 3 residents reviewed (Residents B and C). Fraudulent charges were made on their credit cards by a housekeeper who was subsequently terminated. The deficient practice was corrected prior to the survey.
Complaint Details
Complaints IN00425041 and IN00425093 were substantiated with federal/state deficiencies cited at F602. Complaint IN00425240 had no deficiencies related to the allegations. The investigation revealed fraudulent use of residents' credit cards by a housekeeper, with charges totaling $602 for Resident B and approximately $300 for Resident C. The housekeeper was terminated prior to the survey.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents' credit cards were kept safe and secure during admission, resulting in fraudulent charges by a housekeeper. | SS=D |
Report Facts
Census total residents: 91
Census SNF beds: 6
Census SNF/NF beds: 85
Medicare residents: 12
Medicaid residents: 48
Other payor residents: 31
Fraudulent charges Resident B: 602
Approximate fraudulent charges Resident C: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 1 | Named as the individual who misappropriated residents' credit cards and was terminated | |
| Executive Director | Interviewed regarding the fraudulent charges and investigation |
Inspection Report
Follow-Up
Census: 81
Deficiencies: 0
Dec 18, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00421053 completed on November 16, 2023.
Findings
Spring Mill Meadows was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the Post Survey Revisit to the Investigation of Complaint IN00421053. The complaint was corrected.
Complaint Details
Complaint IN00421053 - Corrected.
Report Facts
Census: 81
Census Bed Type - SNF: 8
Census Bed Type - SNF/NF: 73
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 43
Census Payor Type - Other: 29
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 1
Nov 16, 2023
Visit Reason
This visit was conducted as an investigation of multiple complaints (IN00419557, IN00419943, IN00420014, IN00420528, IN00421053, and IN00421982) regarding the facility's compliance with regulations.
Findings
The facility was found to have a significant medication error involving Resident G, who did not receive ordered potassium chloride liquid as prescribed, resulting in a critically low potassium level and hospital admission. Other complaints were found to have no deficiencies related to the allegations.
Complaint Details
Complaint IN00421053 was substantiated with federal/state deficiencies cited at F760 related to medication errors. Other complaints investigated showed no deficiencies related to the allegations.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer potassium chloride liquid as ordered, resulting in a significant medication error and hospital admission for Resident G. | SS=G |
Report Facts
Census SNF beds: 8
Census SNF/NF beds: 76
Total census: 84
Medicare census: 15
Medicaid census: 48
Other payor census: 21
Potassium levels: 3
Potassium levels: 2.7
Potassium levels: 2.5
Medication doses ordered: 80
Hospital admission duration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Marker-Kump | Executive Director | Signed the report |
| Agency Nurse 4 | Failed to administer potassium chloride liquid as ordered on 10/24/23 | |
| LPN 5 | Advised rescheduling potassium medication to 10/25/23 and changed order dates | |
| Director of Nursing | DON | Interviewed regarding medication error and facility policies |
| Regional Director of Clinical Support | RDCS | Interviewed about facility policy on following physician orders |
| Nurse Practitioner | NP | Ordered potassium replacement and directed emergency transfer after medication error |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 9, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00418345 completed on October 5, 2023.
Findings
Spring Mill Meadows 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 complaint investigation.
Complaint Details
Investigation of Complaint IN00418345 was completed with findings of compliance.
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Oct 5, 2023
Visit Reason
This visit was conducted for the investigation of four complaints (IN00417899, IN00418017, IN00418345, and IN00418427) and included a COVID-19 Focused Infection Control Survey.
Findings
The facility was found deficient related to Complaint IN00418345 for failing to ensure interventions were used to prevent potential decline of a resident's bilateral heel pressure ulcers. The resident's Prevalon boots and pillows were not in use as ordered, and documentation and care planning for refusal of treatment were inadequate.
Complaint Details
Complaint IN00418345 was substantiated with federal/state deficiencies cited at F686. Complaints IN00417899, IN00418017, and IN00418427 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure interventions were used to prevent potential decline to a resident's bilateral heel pressure ulcers. | SS=D |
Report Facts
Census: 79
Census bed type - SNF: 11
Census bed type - SNF/NF: 68
Census payor type - Medicare: 18
Census payor type - Medicaid: 47
Census payor type - Other: 14
Wound measurements - left heel: 4
Wound measurements - left heel width: 3
Wound measurements - right heel: 5
Wound measurements - right heel width: 5.5
Wound measurements - left heel: 3
Wound measurements - left heel width: 2.8
Wound measurements - left heel depth: 0.1
Wound measurements - right heel: 1.7
Wound measurements - right heel width: 3.1
Wound measurements - right heel depth: 0.1
Treatment duration: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Marker-Kump | Executive Director | Signed the report and was present during the survey |
| Director of Nursing | Director of Nursing | Interviewed during survey; provided information about resident care and policies |
| LPN 1 | Observed resident and provided information about wound care and resident's use of Prevalon boots | |
| LPN 3 | Observed resident's wounds and applied Prevalon boots during survey |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Sep 19, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00412748, IN00413192, IN00413565, IN00417301, and IN00417784.
Findings
No deficiencies related to the allegations in any of the 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.
Complaint Details
Complaints IN00412748, IN00413192, IN00413565, IN00417301, and IN00417784 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census Bed Type - SNF: 10
Census Bed Type - SNF/NF: 69
Total Census: 79
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 45
Census Payor Type - Other: 17
Inspection Report
Annual Inspection
Census: 81
Capacity: 130
Deficiencies: 3
Jul 26, 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 July 26, 2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements, with deficiencies related to fire alarm system time accuracy, sprinkler head obstructions, and portable fire extinguisher installation height.
Severity Breakdown
SS=C: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire alarm system failed to maintain accurate time on the control panel. | SS=C |
| Sprinkler head spray pattern was obstructed by a ceiling fan in the kitchen office. | SS=E |
| Portable fire extinguisher in the basement was installed with the top more than five feet above the floor. | SS=E |
Report Facts
Certified beds: 130
Census: 81
Portable fire extinguishers: 27
Fire extinguisher height: 64
Sprinkler clearance: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Marker-Kump | Executive Director | Facility representative who signed the report. |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions; name not provided. |
Inspection Report
Life Safety
Deficiencies: 0
Jul 26, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 07/26/23.
Findings
Spring Mill Meadows 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
Annual Inspection
Census: 76
Capacity: 76
Deficiencies: 5
Jun 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from June 26 to June 30, 2023.
Findings
The facility was found deficient in multiple areas including failure to monitor daily weights as ordered for a resident with CHF, improper transfer techniques for dependent residents, failure to reweigh and notify physician after significant weight loss, failure to label liquid narcotics properly, and incomplete employee screening and training documentation.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to monitor daily weights as ordered for a resident with congestive heart failure. | SS=D |
| Failed to ensure dependent residents were transferred as care planned using proper technique and transfer assist of two. | SS=D |
| Failed to reweigh a resident after significant weight loss and notify physician. | SS=D |
| Failed to label liquid narcotics stored in the narcotic box in the medication cart. | SS=D |
| Failed to ensure appropriate screening items were maintained for prospective employees including references, PPD tests, job orientation, and dementia training. | — |
Report Facts
Census SNF/NF beds: 69
Census SNF beds: 7
Total census: 76
Medicare census: 14
Medicaid census: 47
Other payor census: 15
Weight loss percentage: 20.33
Medication audit dates: 2
Transfers recorded: 52
Two person assist transfers: 12
Transfers recorded: 67
Two person assist transfers: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NA 5 | Certified Nursing Assistant | Employee file missing references, 1st or 2nd step TB test, and job orientation |
| NA 7 | Certified Nursing Assistant | Employee file missing references |
| Cook 8 | Cook | Employee file missing required dementia training |
| Director of Nursing | Director of Nursing | Interviewed regarding weight monitoring and medication labeling policies |
| Executive Director | Executive Director | Interviewed regarding employee files and policies |
Inspection Report
Renewal
Deficiencies: 0
Jun 30, 2023
Visit Reason
Paper compliance review for the Recertification and State Licensure Survey completed on June 30, 2023.
Findings
Spring Mill Meadows 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 for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Apr 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00392802.
Findings
No deficiencies related to the allegations 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 complaint investigation.
Complaint Details
Complaint IN00392802 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 78
Census Payor Type: 78
SNF/NF beds: 69
SNF beds: 9
Medicare residents: 13
Medicaid residents: 48
Other payor residents: 17
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 2
Sep 15, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390136, which was substantiated with federal/state deficiencies cited.
Findings
The facility failed to provide privacy for one resident during an examination and failed to ensure off-loading boots were used for one resident with pressure ulcers. The complaint was substantiated with deficiencies related to personal privacy and treatment to prevent pressure ulcers.
Complaint Details
Complaint IN00390136 was substantiated with federal/state deficiencies cited at F583 and F686 related to privacy and pressure ulcer care.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide privacy for 1 of 1 resident during an examination (Resident C). | SS=D |
| Failed to ensure off-loading boots were in use for 1 of 2 residents reviewed for skin integrity (Resident C). | SS=D |
Report Facts
Census: 72
Total Capacity: 72
Medicare Census: 8
Medicaid Census: 45
Other Payor Census: 19
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 15, 2022
Visit Reason
Paper compliance review for the Investigation of Complaint IN00390136 completed on September 15, 2022.
Findings
Spring Mill Meadows 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 Investigation of Complaint IN00390136.
Complaint Details
Investigation of Complaint IN00390136; paper compliance review completed and found in compliance.
Inspection Report
Deficiencies: 0
Jul 18, 2022
Visit Reason
The visit was conducted to assess paper compliance with the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey.
Findings
Spring Mill Meadows was found in compliance with the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as the Life Safety Code and State Licensure requirements.
Inspection Report
Renewal
Deficiencies: 0
Jun 6, 2022
Visit Reason
The visit was a paper compliance review for the Recertification and State Licensure Survey completed on June 6, 2022.
Findings
Spring Mill Meadows 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.
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