Inspection Reports for
Springhurst Health Campus
628 N Meridian Rd, Greenfield, IN 46140, GREENFIELD, IN, 46140
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
205% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
71% occupied
Based on a May 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jun 17, 2025
Visit Reason
The inspection was conducted in response to multiple complaints alleging inadequate care, dignity violations, staffing shortages, and medication errors at Springhurst Health Campus.
Complaint Details
The inspection relates to complaints IN00461161, IN00461220, IN00460769, IN00461614, and IN00461308 involving dignity violations, abuse reporting failures, staffing shortages, medication errors, and inadequate care.
Findings
The facility failed to promote residents' dignity, timely respond to call lights, report and investigate abuse allegations properly, complete treatments and medication orders as prescribed, and maintain adequate staffing levels to meet residents' needs.
Deficiencies (9)
F0550: The facility failed to promote a resident's dignity by not providing care with respect for 2 of 4 residents reviewed for dignity.
F0558: The facility failed to ensure a resident's call light was within reach for 1 of 1 resident reviewed for call light accessibility.
F0609: The facility failed to immediately report and investigate an allegation of abuse for 2 of 2 residents reviewed for abuse.
F0640: The facility failed to timely transmit a Quarterly Minimum Data Set assessment for 1 of 9 residents reviewed for MDS assessments.
F0677: The facility failed to assist dependent residents with shaving per preference and provide activities of daily living care in a timely manner for 4 of 7 residents reviewed.
F0684: The facility failed to complete treatments as ordered and failed to timely address a medication allergy for 3 of 4 residents reviewed for quality of care.
F0690: The facility failed to ensure a resident's catheter drainage bag and tubing were free of contact with the floor for 1 of 2 residents reviewed for catheters.
F0725: The facility failed to ensure sufficient nursing staff to provide activities of daily living care, skin care treatments, and maintain residents' dignity, affecting all residents.
F0755: The facility failed to follow hospital discharge orders to discontinue medication upon readmission for 1 of 4 residents reviewed for quality of care.
Report Facts
Residents affected: 61
MDS transmission delay: 4
Treatment not completed: 2
Staffing gap: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 9 | Registered Nurse | Refused shift due to inadequate staffing; worked night shift 6/7/25. |
| LPN 10 | Licensed Practical Nurse | Worked night shift 6/7/25 to 6/8/25; took a nap during shift; was not aware by staff. |
| CRCA 6 | Certified Resident Care Assistant | Witnessed abuse incident between residents D and H; reported to RN 5 but not to Executive Director. |
| RN 5 | Registered Nurse | Responded to abuse incident report; called ADHS but did not inform Executive Director. |
| DHS | Director of Health Services | Involved in abuse incident follow-up; unaware of some abuse details; did not speak with CRCA 6. |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Date: May 8, 2025
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00457657 and included the investigation of Residential Complaints IN00458163 and IN00458382.
Complaint Details
Complaint IN00457657 was investigated and found to have no deficiencies related to the allegations.
Findings
Springhurst Health Campus was found to be in substantial compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the Investigation of Complaint IN00457657. No deficiencies related to the allegations were cited.
Report Facts
Census Bed Type Total: 113
Census Payor Type Total: 55
Census Bed Type SNF: 25
Census Bed Type SNF/NF: 30
Census Bed Type Residential: 58
Census Payor Type Medicare: 20
Census Payor Type Medicaid: 23
Census Payor Type Other: 12
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 6, 2025
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00447723 and Residential Complaint IN00451771.
Complaint Details
Complaint IN00447723 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00447723 were cited. The facility was found to be in substantial compliance with applicable regulations.
Report Facts
Census Bed Type Total: 117
Census Payor Type Total: 57
SNF Beds: 28
SNF/NF Beds: 29
Residential Beds: 60
Medicare Residents: 23
Medicaid Residents: 23
Other Payor Residents: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
This visit was conducted to investigate complaints IN00445470 and IN00445952 at Springhurst Health Campus.
Complaint Details
Investigation of complaints IN00445470 and IN00445952 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00445470 and IN00445952 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 32
Census Bed Type - Residential: 51
Census Bed Type - Total: 115
Census Payor Type - Medicare: 29
Census Payor Type - Medicaid: 23
Census Payor Type - Other: 12
Census Payor Type - Total: 64
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Oct 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443602.
Complaint Details
Complaint IN00443602 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440523 at Springhurst Health Campus.
Complaint Details
Complaint IN00440523 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 110
Census Bed Type SNF: 29
Census Bed Type SNF/NF: 30
Census Bed Type Residential: 51
Census Payor Type Medicare: 26
Census Payor Type Medicaid: 24
Census Payor Type Other: 9
Census Payor Type Total: 59
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: Jul 18, 2024
Visit Reason
This visit was for the investigation of residential complaints IN00438510 and IN00438569.
Complaint Details
Complaint IN00438510 and IN00438569 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00438510 and IN00438569 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Re-Inspection
Census: 59
Capacity: 74
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 edition of the NFPA 101 Life Safety Code. The healthcare portion of the facility is fully sprinkled and equipped with fire alarms and smoke detectors.
Inspection Report
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
The visit was a paper compliance review related to the Recertification, State Licensure, Complaint, and Residential survey.
Findings
Springhurst Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review.
Inspection Report
Life Safety
Census: 54
Capacity: 74
Deficiencies: 3
Date: May 23, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements related to egress door signage, hazardous area door self-closing devices, and ground fault circuit interrupter (GFCI) maintenance. Immediate interventions and corrective actions were planned and implemented.
Deficiencies (3)
LSC 7.2.1.6.1. The exit door from the 200 hall into the courtyard had delayed egress locks but lacked the required signage indicating the door can be opened in 15 seconds by pushing.
NFPA 101 hazardous areas. The corridor door to the Business Office near the front entrance did not have a properly working self-closing device, exposing combustible storage to risk.
NFPA 70, NEC 2011. One of over 20 GFCI electric receptacles outside the maintenance area failed to trip and did not break the electrical circuit, risking electric shock to staff.
Report Facts
Certified beds: 74
Resident census: 54
Residents affected: 12
Staff affected: 5
Staff affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Wilson | Executive Director | Signed report and involved in exit conference |
| Plant Operations Director | Interviewed and acknowledged findings related to egress door signage, hazardous area door, and GFCI receptacle | |
| Facilities Support Manager | Interviewed and acknowledged findings related to egress door signage, hazardous area door, and GFCI receptacle |
Inspection Report
Annual Inspection
Census: 112
Deficiencies: 3
Date: Apr 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00419594, IN00430351, IN00431824, IN00431921, and IN00431841. It included a State Residential Licensure Survey.
Complaint Details
Complaints IN00419594 and IN00431921 were substantiated with federal/state deficiencies cited at F677 and F550 respectively. Complaints IN00430351, IN00431824, and IN00431841 had no deficiencies related to the allegations.
Findings
The facility was found to have deficiencies related to resident rights and ADL care for dependent residents, including failure to promote dignity and failure to provide showers as scheduled. Some complaints were substantiated with federal/state deficiencies cited, while others were not. The facility was found in compliance with State Residential Licensure Survey requirements.
Deficiencies (3)
Resident Rights (F550): The facility failed to promote a resident's dignity by telling Resident H to use an incontinence brief instead of a bedpan, and a staff member cursed within hearing distance of Resident F.
ADL Care Provided for Dependent Residents (F677): The facility failed to provide showers as scheduled for 2 of 4 residents reviewed (Residents K and B).
Personnel (F9999): The facility failed to follow up on fingerprint results for LPN 2, who was hired contingent on background check completion.
Report Facts
Census Bed Type Total: 112
Census Bed Type SNF/NF: 27
Census Bed Type SNF: 32
Census Bed Type Residential: 53
Census Payor Type Medicare: 23
Census Payor Type Medicaid: 22
Showers received by Resident K in March 2024: 8
Showers received by Resident B: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in personnel deficiency for failure to follow up on fingerprint background check |
| Keith Wilson | Executive Director | Signed report and interviewed regarding fingerprint follow-up |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 30, 2024
Visit Reason
The inspection was conducted in response to complaints regarding resident dignity and care, specifically allegations of staff cursing at a resident and improper toileting instructions, as well as failure to provide scheduled showers for residents.
Complaint Details
Complaint IN00431921 relates to dignity and respect issues including staff cursing and toileting instructions. Complaint IN00419594 relates to failure to provide scheduled showers. Investigations found no verbal abuse substantiated for the cursing allegation; the employee was suspended during investigation and returned to work after no findings. Shower deficiencies were documented with resident interviews and care plan reviews.
Findings
The facility failed to promote resident dignity by instructing a resident to use an incontinence brief instead of a bedpan and a staff member was alleged to have cursed near a resident. Additionally, the facility failed to provide showers as scheduled for 2 of 4 residents reviewed.
Deficiencies (2)
F 0550: The facility failed to honor residents' rights to dignity and respect by telling Resident H to use an incontinence brief instead of a bedpan and a staff member cursed within hearing distance of Resident F. This affected 2 of 3 residents reviewed for dignity.
F 0677: The facility failed to provide showers as scheduled for 2 of 4 residents reviewed for activities of daily living. Residents K and B did not receive showers as planned according to care plans and documentation.
Report Facts
Residents affected: 2
Residents affected: 2
Shower counts: 9
Shower counts: 4
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
This visit was conducted to investigate Complaint IN00404761 at Springhurst Health Campus.
Complaint Details
Complaint IN00404761 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 120
Census Bed Type SNF/NF: 29
Census Bed Type SNF: 24
Census Bed Type Residential: 67
Census Payor Type Total: 53
Census Payor Type Medicare: 24
Census Payor Type Medicaid: 19
Census Payor Type Other: 77
Inspection Report
Life Safety
Census: 52
Capacity: 74
Deficiencies: 0
Date: Apr 26, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
Springhurst Health Campus was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code from Fire, and applicable state regulations. The facility was fully sprinkled and had appropriate fire alarm and smoke detection systems.
Inspection Report
Life Safety
Census: 55
Capacity: 74
Deficiencies: 6
Date: Mar 14, 2023
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and an Emergency Preparedness Survey in accordance with 42 CFR 483.73.
Findings
The facility was found in compliance with Emergency Preparedness requirements but not in compliance with Life Safety Code requirements. Multiple deficiencies were identified related to corridor width, fire alarm system installation, corridor doors, smoke barrier doors, electrical equipment usage, and gas equipment signage.
Deficiencies (6)
NFPA 101 19.2.3.4(5) - The facility failed to maintain clear corridor width due to unsecured benches extending into the corridor, affecting exit access for approximately 30 residents, staff, and visitors.
NFPA 101 18.3.4.1, 19.3.4.1 - The fire alarm control panel door was not locked, allowing unauthorized access and potentially affecting all occupants.
NFPA 101 19.3.6.3 - A corridor door was propped open with a wheeled scale, preventing it from closing and resisting smoke passage, affecting 15 residents.
NFPA 101 19.3.7.8 - Smoke barrier doors had excessive gaps preventing proper smoke containment, affecting 20 residents in two compartments.
NFPA 101 10.2.3.6 - Two power strips were used as a substitute for fixed wiring to power high current draw equipment in the salon, affecting up to 3 residents and 2 staff.
NFPA 99 11.5.2.3.1 - The liquid oxygen storage/transfer room lacked signage indicating when transfilling is occurring, affecting 20 residents in one smoke compartment.
Report Facts
Certified beds: 74
Census: 55
Residents affected: 30
Residents affected: 15
Residents affected: 20
Residents affected: 3
Staff affected: 2
Residents affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Hopkins | Executive Director | Named in report signature and exit conference |
| Plant Operations Director | Interviewed and acknowledged deficiencies related to corridor width, fire alarm panel, corridor doors, smoke barrier doors, electrical equipment, and gas equipment signage | |
| Facilities Support Manager | Interviewed and acknowledged deficiencies related to corridor width, fire alarm panel, corridor doors, smoke barrier doors, electrical equipment, and gas equipment signage |
Inspection Report
Routine
Deficiencies: 12
Date: Feb 27, 2023
Visit Reason
Routine inspection of Springhurst Health Campus to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare Non-Coverage notices, bed hold notifications, care plan meetings, scheduled showers, coordination with hospice care, pressure ulcer care, fall interventions, nutritional follow-up, respiratory care infection control, pharmacy recommendation follow-up, dental care, and medication administration hygiene.
Deficiencies (12)
F 0582: Failed to provide Resident 207 with a Notification of Medicare Non-Coverage at least two calendar days prior to discharge from Medicare Part A services.
F 0625: Failed to provide written bed hold information for Resident 15 upon transfer to hospital or therapeutic leave.
F 0657: Failed to complete a care plan meeting for Resident 43 within seven days of comprehensive assessment.
F 0677: Failed to provide scheduled showers for dependent Residents 30 and 9, with Resident 30 receiving only 4 showers in 37 days and Resident 9 receiving two showers and two bed baths in three months.
F 0684: Failed to ensure collaboration with hospice provider for Resident 17, failed to ensure weekly wound assessments for Resident 22, failed to ensure device use for limited range of motion for Resident 22, and failed to follow Registered Dietitian recommendations for Resident 26.
F 0686: Failed to ensure weekly measurements and treatment of pressure ulcers and prevent prolonged positioning for Residents 17 and 22.
F 0689: Failed to ensure fall interventions and complete neurological checks after falls for Residents 17, 31, and 9.
F 0692: Failed to follow up with Registered Dietitian recommendations for nutritional supplements for Resident 26 who experienced significant weight loss.
F 0695: Failed to store oxygen nasal cannula and C-PAP mask in bags and failed to date oxygen tubing for Residents 45 and 163.
F 0756: Failed to timely follow up on pharmacy recommendations to change potentially inappropriate medications for Residents 9 and 31.
F 0790: Failed to provide routine dental services for Resident 15 who had missing or broken teeth and difficulty chewing.
F 0880: Failed to ensure medications were not handled by bare hands during medication administration observation for Resident 45.
Report Facts
Showers received: 4
Pharmacy recommendation date: Dec 28, 2022
Weight measurements: 165.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Interviewed regarding multiple deficiencies including bed hold notices, hospice coordination, medication administration, and pharmacy follow-up. | |
| Executive Director | Interviewed regarding failure to provide Medicare Non-Coverage notice. |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 16
Date: Feb 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey.
Findings
The facility was found to have multiple deficiencies including failure to provide timely Medicaid/Medicare notices, bed hold notices, care plan meetings, scheduled showers, coordination with hospice, pressure ulcer care, fall interventions, respiratory care, medication administration, dental services, infection control, and personnel record compliance.
Deficiencies (16)
F582 – Medicaid/Medicare Coverage/Liability Notice: Facility failed to provide Resident 207 with a Notification of Medicare Non-Coverage at least two calendar days prior to discharge from Medicare Part A services.
F625 – Notice of Bed Hold Policy Before/Upon Transfer: Facility failed to provide written bed hold information for 1 of 2 residents reviewed for hospitalization (Resident 15).
F657 – Care Plan Timing and Revision: Facility failed to complete a care plan meeting for 1 of 1 resident reviewed for care plan meetings (Resident 43).
F677 – ADL Care Provided for Dependent Residents: Facility failed to provide showers as scheduled for dependent residents for 2 of 2 reviewed (Resident 30 and Resident 9).
F684 – Quality of Care: Facility failed to ensure collaboration with hospice provider regarding coordination of care related to laboratory work, medication changes, wound assessments, RD recommendations, and failed to ensure a device was in place per physician orders for limited range of motion for 3 residents.
F686 – Treatment/Services to Prevent/Heal Pressure Ulcer: Facility failed to ensure weekly measurements of pressure ulcers, provide treatment as ordered, and ensure residents with pressure ulcers did not stay in the same position for extended periods for 2 of 5 residents reviewed.
F689 – Free of Accidents Hazards/Supervision/Devices: Facility failed to ensure fall interventions were in place per care plan and ensure fall follow-up included completed neurological checks for 3 of 4 residents reviewed for accidents.
F692 – Nutritional/Hydration Status Maintenance: Facility failed to follow up with Registered Dietitian recommendations for a supplement for a resident who experienced significant weight loss (Resident 26).
F695 – Respiratory/Tracheostomy Care and Suctioning: Facility failed to store oxygen nasal cannula and C-PAP mask in a bag for infection control and failed to date oxygen tubing for 2 of 2 residents reviewed for respiratory care.
F756 – Drug Regimen Review, Report Irregular, Act On: Facility failed to ensure pharmacy recommendations were followed up timely for 2 of 5 residents reviewed for unnecessary medications (Resident 31 and Resident 9).
F790 – Routine/Emergency Dental Services in SNFs: Facility failed to provide routine dental services for a resident who had missing or broken teeth and difficulty chewing (Resident 15).
F880 – Infection Prevention & Control: Facility failed to ensure medications were not handled by bare hands during medication administration observation (Resident 45).
R9999 – Final Observations: Facility failed to complete required pre-employment screening, orientation, and training for 10 of 10 staff members reviewed for employee records.
R0119 – Personnel Noncompliance: Facility failed to complete a complete orientation for 2 of 5 employee records reviewed.
R0120 – Personnel Noncompliance: Facility failed to have required dementia training for 5 of 5 employee records reviewed.
R0121 – Personnel Noncompliance: Facility failed to ensure staff had an annual Mantoux test and/or tuberculosis risk assessment for 3 of 5 employee records reviewed.
Report Facts
Residents reviewed: 5
Residents reviewed: 5
Residents reviewed: 2
Residents reviewed: 3
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 2
Residents reviewed: 2
Residents reviewed: 3
Employees reviewed: 10
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 27, 2023
Visit Reason
The visit was a paper compliance review for the Recertification, State Licensure which included a Residential survey completed on February 27, 2023.
Findings
Springhurst Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for Recertification, State Licensure and Residential survey.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
This visit was for the investigation of Complaint IN00393347.
Complaint Details
Complaint IN00393347 was substantiated. No deficiencies related to the allegations were cited.
Findings
Springhurst Health Campus was found to be in substantial compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the Investigation of Complaint IN00393347. No deficiencies related to the allegations were cited.
Report Facts
Census Bed Type Total: 96
Census Bed Type SNF: 19
Census Bed Type SNF-NF: 32
Census Bed Type Residential: 45
Census Payor Type Medicare: 15
Census Payor Type Medicaid: 17
Census Payor Type Other: 19
Census Payor Type Total: 51
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 0
Date: Aug 9, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00383776 completed on 2022-07-06.
Complaint Details
Complaint IN00383776 was corrected.
Findings
Springhurst Health Campus was found to be in compliance with 410 IAC 16.2-5 in regards to the PSR to the Investigation of Complaint IN00383776.
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