Inspection Report Summary
The most recent inspection on May 28, 2025, identified a deficiency related to a staff member’s failure to use a gait belt during a resident transfer, which resulted in a fall with injury; this issue was corrected prior to the survey. Earlier inspections showed a pattern of deficiencies primarily involving quality of care, medication management, accident prevention, and safety measures such as fire and life safety code compliance. Several complaint investigations were substantiated, including medication errors, inadequate cancer care, and failure to secure residents’ property, while many other complaints were found unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows ongoing challenges in care and safety areas, with some corrections made promptly but no clear overall trend of sustained improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
221% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
83 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Deficiencies: 11
Aug 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including medication self-administration, beneficiary notices, PASARR updates, baseline and comprehensive care plans, physician orders, medication storage, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure proper interdisciplinary team evaluation and physician orders for medication self-administration, incomplete beneficiary notice documentation, outdated PASARR assessments, delayed baseline care plans, incomplete care plan meetings, failure to follow physician orders for weights and bladder scans, lack of physician order for oxygen use, inadequate documentation of rationale for declined pharmacist recommendations, improper medication labeling, failure to monitor refrigerator temperatures and discard expired food, and lapses in infection control practices including PPE use and equipment storage.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure interdisciplinary team determined resident safety and obtained physician order for self-administration of medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Notice of Medicare Non-Coverage was signed by resident or representative. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update PASARR when new diagnoses or psychotropic medications were added. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop baseline care plans within 48 hours including enhanced barrier precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to hold quarterly care plan meetings, invite residents/representatives, and develop comprehensive care plans related to PICC line and enhanced barrier precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician orders for weekly weights and notification for bladder scans over 400 ml. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician's order for oxygen use was prescribed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure attending physician documented rationale for not acting on pharmacist's recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication bottles were labeled with open dates and medication labels were legible. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor and document refrigerator temperatures and discard expired food items. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper use of PPE during care for residents on Enhanced Barrier Precautions, proper signage, and proper storage of bed pans. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 11
Physician order dates: 6
Medication doses: 4.5
Bladder scan volumes: 600
Refrigerator temperature: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided interviews and facility policies related to multiple deficiencies including medication self-administration, care plans, and infection control. |
| Social Service Worker 6 | Social Service Worker | Interviewed regarding PASARR updates and care plan meetings. |
| Social Service Worker 7 | Social Service Worker | Interviewed regarding care plan meetings and enhanced barrier precautions. |
| Registered Nurse 16 | Registered Nurse | Interviewed regarding oxygen orders and bladder scan notifications. |
| Clinical Support Nurse | Clinical Support Nurse | Interviewed regarding baseline care plans and physician orders. |
| Unit Manager 9 | Unit Manager | Interviewed regarding improper storage of bed pan. |
| QMA 12 | Qualified Medication Aide | Observed and interviewed regarding PPE use during care. |
| LPN 1 | Licensed Practical Nurse | Observed and interviewed regarding PPE use during medication administration. |
| CNA 5 | Certified Nursing Assistant | Observed during catheter care and PPE use. |
| Kitchen Manager | Kitchen Manager | Interviewed regarding refrigerator temperature and food safety. |
| Infection Preventionist | Infection Preventionist | Observed catheter care and provided infection control guidance. |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 28, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to a fall incident involving Resident B, where the facility failed to ensure staff followed policy regarding gait belt use during transfers.
Findings
The facility failed to ensure a staff member used a gait belt during a transfer, resulting in Resident B falling and sustaining an abrasion and a right femur fracture. The deficient practice was corrected prior to the survey start date.
Complaint Details
This citation relates to Complaint IN00458980.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff used a gait belt during resident transfer, resulting in a fall with injury. | Level of Harm - Actual harm |
Report Facts
Residents affected: 3
Residents affected: Few
Date of fall incident: May 4, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Failed to use gait belt during transfer resulting in resident fall |
| Director of Nursing | Confirmed gait belt use policy and staff training | |
| Director of Therapy | Provided therapy evaluation indicating gait belt use |
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
Deficiencies: 1
Feb 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation (Complaint IN00451659) regarding the facility's failure to ensure appropriate treatment and follow-up care for a resident with metastatic prostate cancer.
Findings
The facility failed to ensure Resident B received prescribed cancer medication (Nubeqa) as ordered, did not schedule timely follow-up oncology appointments, and the medical director discontinued the medication without consulting the oncologist. This resulted in Resident B having no oncology follow-up care for 15 months, leading to cancer progression and transition to hospice care.
Complaint Details
This citation relates to Complaint IN00451659. The complaint involved failure to provide ordered cancer medication and follow-up oncology care for Resident B, resulting in actual harm.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically related to cancer medication and follow-up oncology care for Resident B. | Level of Harm - Actual harm |
Report Facts
Residents Affected: 1
Medication dosage: 600
Timeframe without oncology follow-up: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding Resident B's chemotherapy drug orders and medication discontinuation |
| Medical Director | Discontinued Resident B's cancer medication without oncologist consultation; no name provided |
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
Complaint Investigation
Deficiencies: 3
Aug 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to issues including incorrect resident transfer arrangements, medication administration errors, and failure to follow physical therapy transfer recommendations.
Findings
The facility failed to ensure correct transfer arrangements for a resident, failed to notify physicians as ordered regarding medication parameters and missed doses for multiple residents, and failed to follow physical therapy recommendations for safe resident transfers. These deficiencies were corrected prior to or during the survey.
Complaint Details
This citation relates to Complaint IN00435561 for transfer issues, Complaint IN00439059 for medication administration, and Complaint IN00429846 for transfer safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure a facility arranged transfer included the correct address of the receiving facility for 1 of 1 resident reviewed for discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure the physician was notified as ordered, to hold medications according to physician's ordered hold parameters, and to ensure medications were given as ordered for 5 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure the physical therapy recommended method to transfer a resident was used for 1 of 5 residents reviewed for accidents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 1
Missed medication doses: 4
Missed medication doses: 3
Missed medication doses: 1
Missed medication doses: 3
Blood pressure readings: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication notification and transfer issues |
| Social Services Director | Social Services Director | Made arrangements for resident transfer; gave wrong address to transport company |
| Executive Director | Executive Director | Acknowledged human error in providing wrong address for resident transfer |
| Director of Therapy | Director of Therapy | Interviewed regarding transfer recommendations and documentation |
| Anonymous staff member | Interviewed regarding medication administration practices |
Inspection Report
Complaint Investigation
Deficiencies: 5
Aug 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about resident transfers, medication management, dental services, medication storage, and food safety at the facility.
Findings
The facility was found deficient in multiple areas including failure to use recommended transfer methods for a resident, delayed AIMS assessments and lack of education on antipsychotic black box warnings, improper medication storage and narcotic reconciliation, failure to assist a resident in obtaining dentures, and inadequate food storage practices in the walk-in freezer.
Complaint Details
This citation relates to Complaint IN00429846.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure the physical therapy recommended method to transfer a resident was used for 1 of 5 residents reviewed for accidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete an abnormal involuntary movement scale (AIMS) assessment timely and did not educate about black box warnings for antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication carts were free of loose medications, label an inhaler, keep narcotic cards free of compromise, and ensure narcotic count log accuracy for 3 medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist a resident to obtain dentures as recommended during a dental exam for 1 of 3 residents reviewed for dental services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure frozen foods were sealed and free of moisture in the walk-in freezer. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 5
Residents reviewed for dental services: 3
Medication carts reviewed: 3
Medication doses: 16
Medication doses: 15
Weight of frozen foods: 10
Weight of frozen foods: 5
Weight of frozen foods: 13.5
Weight of frozen foods: 18.9
Weight of frozen foods: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Therapy | Interviewed regarding transfer recommendations and order placement | |
| CNA 6 | Certified Nursing Assistant | Provided written statement about resident transfer incident |
| Director of Nursing | DON | Interviewed regarding AIMS assessment and medication destruction procedures |
| Executive Director | ED | Interviewed regarding education on black box warnings and medication policies |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding medication cart observations and narcotic reconciliation |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding medication destruction procedures |
| Unit Manager | Interviewed regarding narcotic card procedures | |
| Social Services Assistant | Interviewed regarding dental services and denture procurement | |
| Dietary Manager | Interviewed regarding freezer conditions and food safety | |
| Maintenance Supervisor | Interviewed regarding freezer defrosting and moisture issues | |
| Administrator | Interviewed regarding freezer auto defrost function |
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
Deficiencies: 1
Feb 2, 2024
Visit Reason
The inspection was conducted in response to complaints regarding misappropriation of residents' property, specifically fraudulent use of residents' credit cards by a staff member.
Findings
The facility failed to ensure residents' credit cards were kept safe and secure during admission, resulting in fraudulent charges on two residents' credit cards by a housekeeper. The issue was corrected prior to the survey by terminating the implicated employee and implementing staff training on misappropriation of property.
Complaint Details
This citation relates to Complaint IN00425041 and IN00425093. The complaints involved fraudulent charges on residents' credit cards, with investigations confirming misuse by a housekeeper who was subsequently terminated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to protect residents from wrongful use of their belongings or money, specifically credit card misappropriation by a housekeeper. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Fraudulent charges amount: 602
Fraudulent charges amount: 300
Date of survey completion: Feb 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 1 | Named as the staff member who misappropriated residents' credit cards and was terminated | |
| Executive Director | Interviewed regarding the fraudulent charges and investigation |
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
Deficiencies: 1
Nov 16, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding medication errors involving Resident G, specifically the failure to administer potassium replacement as ordered, which led to a hospital admission.
Findings
The facility failed to administer potassium liquid as ordered to Resident G, resulting in a critically low potassium level and subsequent hospital transfer. The investigation revealed medication rescheduling without notifying the Nurse Practitioner, lack of policy adherence, and medication availability issues.
Complaint Details
The complaint was substantiated and related to medication errors involving Resident G, who had a critically low potassium level and was not treated with the ordered potassium replacement, leading to hospitalization.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer potassium liquid as ordered, resulting in a critically low potassium level and hospital admission. | Level of Harm - Actual harm |
Report Facts
Potassium levels: 3
Potassium levels: 2.7
Potassium levels: 2.5
Potassium level: 2.2
Potassium dosage: 20
Potassium dosage total: 80
Medication doses not administered: 3
Hospital admission duration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Agency Nurse 4 | Named in medication error for not administering potassium liquid as ordered on 10/24/23 | |
| LPN 5 | Involved in rescheduling potassium liquid medication and lab orders | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication error and facility policies |
| Regional Director of Clinical Support | Regional Director of Clinical Support (RDCS) | Interviewed regarding lack of policy for following physician orders |
| Nurse Practitioner | Nurse Practitioner (NP) | Ordered potassium replacement and provided clinical assessment |
| Executive Director | Executive Director (ED) | Provided facility medication administration policies |
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
Annual Inspection
Deficiencies: 0
Oct 5, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 5, 2023
Visit Reason
The inspection was conducted based on a complaint (IN00418345) regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in a resident with bilateral heel pressure ulcers.
Findings
The facility failed to ensure interventions were used to prevent decline in a resident's bilateral heel pressure ulcers. Observations showed the resident was not wearing prescribed offloading boots and pillows were not used as an alternative. Documentation and care plans were incomplete regarding refusal of treatment and alternative approaches. The resident's wounds were unstageable and had been treated with Betadine daily, but offloading orders were inconsistently applied.
Complaint Details
This Federal tag relates to Complaint IN00418345.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for 1 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| No order written for floating heels/ankles with pillows as part of offloading plan despite wound care treatment plan. | Level of Harm - Minimal harm or potential for actual harm |
| Lack of documentation that resident or representative was educated on condition, treatment options, expected outcomes, and consequences of refusing Prevalon boots. | Level of Harm - Minimal harm or potential for actual harm |
| No care plan addressing resident refusal of Prevalon boots and alternative approaches. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Wound measurement: 4
Wound measurement: 5
Wound measurement: 3
Wound measurement: 1.7
Duration of wound treatment: 14
Treatment shifts: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Participated in observation and interview regarding resident's refusal of Prevalon boots and care plan |
| LPN 1 | Licensed Practical Nurse | Observed resident without boots and pillows, participated in wound observation |
| LPN 3 | Licensed Practical Nurse | Observed and described resident's heel wounds and treatment |
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
Annual Inspection
Deficiencies: 4
Jun 30, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, nutrition, medication management, and facility policies.
Findings
The facility was found deficient in several areas including failure to monitor daily weights as ordered for a resident with congestive heart failure, failure to ensure dependent residents were transferred using proper technique and assist levels, failure to reweigh a resident after significant weight loss and notify the physician, and failure to label liquid narcotics properly in medication carts.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to monitor daily weights as ordered for a resident with congestive heart failure. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dependent residents were transferred as care planned using proper technique and two-person assist for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to reweigh a resident after significant weight loss and notify physician. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label liquid narcotics stored in the narcotic box in the medication cart. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication carts reviewed: 3
Transfers: 52
Two person assist transfers: 12
Transfers: 67
Two person assist transfers: 4
Weight loss percentage: 20.33
Medication remaining: 28.25
Medication remaining: 27.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding lack of CHF policy, weight monitoring, and medication labeling |
| CNA 5 | Certified Nursing Assistant | Interviewed regarding resident transfer procedures |
| CNA 6 | Certified Nursing Assistant | Observed attempting to transfer resident unassisted |
| Executive Director | Executive Director | Provided medication removal policy |
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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