Inspection Reports for The Springs of Mooresville
302 NORTH JOHNSON ROAD, IN, 46158
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 3, 2024, found no deficiencies related to the complaint investigated. Earlier inspections showed a generally compliant record with occasional deficiencies related mainly to care plan updates and life safety code issues, such as emergency power system maintenance and electrical safety measures. Complaint investigations during this period were consistently unsubstantiated, with no deficiencies cited. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. The facility’s inspection history indicates some isolated issues but overall compliance, with recent inspections showing improvement in addressing prior deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
65 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Dec 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447187.
Findings
No deficiencies related to the allegations in Complaint IN00447187 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00447187 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 65
Census Payor Type Total: 47
Census Bed Type SNF/NF: 22
Census Bed Type SNF: 25
Census Bed Type Residential: 18
Census Payor Type Medicare: 19
Census Payor Type Medicaid: 22
Census Payor Type Other: 6
Inspection Report
Life Safety
Census: 49
Capacity: 70
Deficiencies: 0
Sep 3, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility is a one-story, fully sprinklered Type V (111) construction with a fire alarm system and hard-wired smoke detection in corridors and resident sleeping rooms.
Report Facts
Certified beds: 70
Census: 49
Inspection Report
Renewal
Census: 47
Capacity: 65
Deficiencies: 0
Aug 21, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over multiple days in August 2024.
Findings
The Springs of Mooresville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Bed Type Total: 65
Census Payor Type Total: 47
Inspection Report
Complaint Investigation
Census: 50
Capacity: 67
Deficiencies: 0
Aug 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435328.
Findings
No deficiencies related to the allegations in Complaint IN00435328 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00435328 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 67
Census Payor Type Total: 50
Census by Bed Type: 22
Census by Bed Type: 28
Census by Bed Type: 17
Census by Payor Type: 19
Census by Payor Type: 22
Census by Payor Type: 9
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Mar 18, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00427852 and Residential Complaint IN00429566.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Nursing Home Complaint IN00427852 and Residential Complaint IN00429566; no deficiencies related to allegations were cited.
Report Facts
Census Bed Type Total: 65
Census Payor Type Total: 47
Census Bed Type SNF/NF: 21
Census Bed Type SNF: 26
Census Bed Type Residential: 18
Census Payor Type Medicare: 18
Census Payor Type Medicaid: 21
Census Payor Type Other: 8
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Feb 1, 2024
Visit Reason
This visit was conducted to investigate complaints IN00427168 and IN00427372 at The Springs of Mooresville.
Findings
No deficiencies related to the allegations in complaints IN00427168 and IN00427372 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of complaints IN00427168 and IN00427372 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 29
Census Bed Type - SNF/NF: 18
Census Bed Type - Residential: 18
Census Bed Type - Total: 65
Census Payor Type - Medicare: 19
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 10
Census Payor Type - Total: 47
Inspection Report
Complaint Investigation
Census: 44
Capacity: 63
Deficiencies: 0
Jan 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00424175 and IN00424865.
Findings
No deficiencies related to the allegations in Complaints IN00424175 and IN00424865 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00424175 and IN00424865 found no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 63
Census Payor Type Total: 44
Census SNF/NF: 19
Census SNF: 25
Census Residential: 19
Census Medicare: 18
Census Medicaid: 19
Census Other: 7
Inspection Report
Complaint Investigation
Census: 42
Capacity: 61
Deficiencies: 0
Dec 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423011.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00423011 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 42
Total Capacity: 61
Medicare Census: 13
Medicaid Census: 21
Other Payor Census: 8
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 11, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey.
Findings
The facility 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 the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 43
Capacity: 70
Deficiencies: 2
Oct 10, 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 in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, specifically failing to implement emergency power system inspection, testing, and maintenance requirements, including the absence of annual fuel quality test results for the diesel generator.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements as per Health Care Facilities Code, NFPA 110, and Life Safety Code. | SS=F |
| No annual fuel quality test results available for the diesel generator from the 06/30/23 sampling; most recent results dated 06/29/22. | SS=F |
Report Facts
Certified beds: 70
Census: 43
Deficiencies cited: 2
Compliance date: Oct 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Padgett | Administrator | Signed the report |
| Director of Plant Operations | Interviewed regarding emergency power system deficiencies and fuel quality testing | |
| Executive Director | Involved in education and QAPI committee for compliance follow-up |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 10, 2023
Visit Reason
The document reports on paper compliance for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey conducted on 10/10/2023.
Findings
The Springs of Mooresville was found in compliance with the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, and with the Life Safety Code and State Licensure requirements.
Report Facts
Facility Number: 13694
Provider Number: 155842
AIM Number: 300018361
Inspection Report
Renewal
Census: 43
Capacity: 62
Deficiencies: 1
Sep 26, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from September 19 to 26, 2023.
Findings
The facility failed to revise a care plan for a resident who experienced significant weight loss. Resident 3 had notable weight loss without updated nutrition care plan interventions since April 27, 2023. The facility provided education and audits to ensure care plans for residents with significant weight loss are updated and interventions communicated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to revise a care plan for a resident who experienced significant weight loss. | SS=D |
Report Facts
Census Bed Type - Total: 62
Census Payor Type - Total: 43
Weight loss percentage: 12.74
Weight loss percentage: 8.19
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Padgett | Administrator | Signed the report |
| Director of Health Services | Interviewed regarding resident weight loss and care plan updates | |
| Assistant Director of Health Services | Interviewed regarding resident weight loss and care plan updates |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 67
Deficiencies: 0
Apr 19, 2023
Visit Reason
This visit was for the investigation of complaints IN00400356 and IN00405830.
Findings
No deficiencies related to the allegations in complaints IN00400356 and IN00405830 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00400356 and IN00405830 found no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 67
Census Payor Type Total: 49
Census SNF/NF: 20
Census SNF: 29
Census Residential: 18
Census Medicare: 21
Census Medicaid: 20
Census Other: 8
Inspection Report
Re-Inspection
Census: 66
Capacity: 70
Deficiencies: 0
Nov 2, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/28/22 by the Indiana Department of Health.
Findings
The Springs of Mooresville was found in compliance with Requirements for Participation Medicare/Medicaid 42 CFR Subpart 483.90(a), 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
Life Safety
Census: 66
Capacity: 70
Deficiencies: 1
Sep 28, 2022
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).
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to ensure ground fault circuit interrupter (GFCI) protection for one electric receptacle within six feet of a kitchen prep sink. Immediate intervention was taken to replace the breaker with a GFCI breaker.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 10 wet locations was provided with ground fault circuit interrupter (GFCI) protection against electric shock near the kitchen prep sink. | SS=D |
Report Facts
Certified beds: 35
Census: 31
Facility capacity: 70
Census: 66
Wet locations inspected: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Named in relation to the GFCI deficiency and corrective actions |
Inspection Report
Renewal
Census: 50
Capacity: 68
Deficiencies: 1
Aug 31, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over multiple days in August 2022.
Findings
The facility was found to be in compliance with applicable regulations regarding the Recertification and State Licensure Survey. However, a deficiency was identified related to service plans not being signed by residents or their representatives for 6 of 7 residents reviewed.
Deficiencies (1)
| Description |
|---|
| Failed to ensure service plans were signed by the resident or resident's representative for 6 of 7 residents reviewed. |
Report Facts
Census Bed Type Total: 68
Census Payor Type Total: 50
Residents affected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Nurse Specialist | Interviewed and indicated service plans lacked signatures | |
| Director of Nursing Services | Interviewed and indicated lack of recent service plan documentation for Resident 5 |
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