Inspection Reports for The Springs of Richmond
400 INDUSTRIES ROAD, RICHMOND, IN, 47374
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 7, 2025, found the facility in compliance with all relevant regulations and corrected all cited complaints. Prior inspections showed a pattern of deficiencies related mainly to resident care issues such as medication management, timely assistance, documentation accuracy, and wound and nutritional care. Several complaint investigations were substantiated, including concerns about pressure ulcer assessments, call light response, and care planning, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Earlier Life Safety Code surveys identified fire safety and maintenance deficiencies, which were addressed in subsequent revisits. The facility’s inspection history indicates some ongoing challenges with resident care and documentation, though recent inspections suggest improvements in compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
240% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
62 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 62
Deficiencies: 0
Date: Jul 7, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00459458, IN00459544, IN00460139, IN00460166, and IN00460478 completed on June 4, 2025.
Complaint Details
This visit was related to the investigation of five complaints (IN00459458, IN00459544, IN00460139, IN00460166, IN00460478). All complaints were corrected as of this visit.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the PSR to the Investigation of Complaints. All cited complaints were corrected.
Report Facts
Census Bed Type - SNF/NF: 6
Census Bed Type - SNF: 41
Census Bed Type - Residential: 15
Census Bed Type - Total: 62
Census Payor Type - Medicare: 36
Census Payor Type - Medicaid: 6
Census Payor Type - Other: 5
Census Payor Type - Total: 47
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 5
Date: Jun 4, 2025
Visit Reason
This visit was for the investigation of multiple complaints (IN00459458, IN00459544, IN00460139, IN00460166, and IN00460478) regarding alleged deficiencies at the facility.
Complaint Details
The investigation was triggered by complaints IN00459458, IN00459544, IN00460139, IN00460166, and IN00460478. Deficiencies were substantiated for all except complaint IN00460478, which had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity and timely assistance, failure to assess safe self-administration of medications, failure to timely follow up on hemolyzed lab results leading to hospitalization, failure to ensure accurate and timely receipt of medications, and failure to accurately document resident behaviors including refusals of care and verbal aggression.
Deficiencies (5)
Failed to promote the dignity of 2 of 3 residents reviewed for the need of assistance, including delayed response to call lights.
Failed to assess a resident for safe self-administration of medication for 1 of 3 residents reviewed.
Failed to timely follow up on hemolyzed lab results for 1 of 3 residents reviewed, resulting in hospitalization.
Failed to ensure 1 of 4 residents reviewed received medications as ordered by their physician.
Failed to accurately reflect behaviors, including refusal of care and verbal aggression, for 1 of 5 residents reviewed for abuse.
Report Facts
Census: 67
Medicare residents: 41
Medicaid residents: 7
Other payor residents: 4
SNF/NF beds: 7
SNF beds: 45
Residential beds: 15
Missed medications: 7
Hemoglobin lab values: 7.2
Hemoglobin lab values: 5.5
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Named in medication administration error where Resident B's morning medications were not administered on 5-1-25. |
| LPN 19 | Licensed Practical Nurse | Provided care to Resident C and witnessed unlabeled medications; did not complete self-administration assessment. |
| LPN 20 | Licensed Practical Nurse | Described medication verification process and Resident C's resistive behavior. |
| Corporate Nurse | Provided policy information and interviews regarding call light response times, medication self-administration, and lab procedures. | |
| Executive Director | Interviewed regarding medication error involving Resident B. | |
| Director of Nursing | Interviewed regarding lab follow-up and staff supervision. |
Inspection Report
Life Safety
Census: 47
Capacity: 70
Deficiencies: 0
Date: Mar 31, 2025
Visit Reason
Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Springs of Richmond 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinkled with a fire alarm system and smoke detectors in all resident sleeping rooms.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification, State Licensure survey, and the Investigation of Complaint IN00444990 completed on February 14, 2025.
Complaint Details
Complaint IN00444990 was investigated and found to be corrected.
Findings
The Springs of Richmond 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 of the recertification, state licensure survey, and complaint investigation. The complaint IN00444990 was corrected.
Inspection Report
Annual Inspection
Census: 52
Capacity: 70
Deficiencies: 5
Date: Mar 3, 2025
Visit Reason
An annual Life Safety Code Recertification and State Licensure survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) on 03/03/2025.
Findings
The facility was found not in compliance with Life Safety Code requirements, including fire barrier penetrations, cooking appliance placement under hood extinguishing system, fire drill scheduling, electrical equipment power cords, and testing and maintenance of patient care related electrical equipment.
Deficiencies (5)
Failed to ensure penetration in 1 of 1 fire barrier walls separating health care from assisted living was properly sealed to maintain fire resistance.
Failed to provide an approved method for returning cooking appliances to approved design location under kitchen hood extinguishing system.
Failed to conduct quarterly fire drills on unexpected days and at unexpected times under varying conditions.
Failed to ensure 1 of 1 flexible cords power strip powering medical equipment met required UL rating of 1363A or 60601-1.
Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Certified beds: 70
Census: 52
Fire barrier penetrations: 3
Fire drills conducted: 9
Fire drills required: 12
Cooking appliances affected: 3
Staff affected: 7
Residents potentially affected: 25
Residents potentially affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin J Meier | Executive Director | Acknowledged findings and participated in exit conference |
| Director of Plant Operations | Acknowledged findings, implemented corrective actions, and participated in interviews | |
| Facilities Management Support | Acknowledged findings, provided education, and participated in interviews |
Inspection Report
Recertification
Census: 51
Capacity: 66
Deficiencies: 9
Date: Feb 11, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00444990, IN00445166, IN00447250, and IN00452120. This visit included a State Residential Licensure Survey.
Complaint Details
This citation is related to Complaint IN00444990. Federal/State deficiencies related to the allegations are cited at F0755. Complaints IN00445166, IN00447250, and IN00452120 had no deficiencies related to the allegations cited.
Findings
The facility was found to be in substantial compliance with state and federal requirements. Several deficiencies were cited related to medication administration, homelike environment, bowel management, tube feeding, respiratory care, pain management, pharmacy services, drug regimen review, and infection control practices.
Deficiencies (9)
Failed to ensure a resident was deemed appropriate to self-administer a nebulizer medication for 1 of 5 residents reviewed for medication administration (Resident 207).
Failed to provide a homelike environment for 1 of 2 residents reviewed (Resident 14) due to molding off the wall and paint missing behind the bed.
Failed to ensure a resident's bowel movements were documented and followed up when a resident went over three days without a bowel movement for 1 of 1 resident reviewed for constipation (Resident G).
Failed to ensure a gastric tube feeding and water flushes were administered as ordered by the physician for 1 of 4 residents reviewed for nutrition (Resident 299).
Failed to date oxygen tubing for 1 of 1 resident reviewed for respiratory care needs (Resident 253).
Failed to ensure effective pain management was provided for a resident who voiced concerns of pain for 1 of 3 residents reviewed for pain medication (Resident 251).
Failed to ensure an antibiotic was administered according to physician orders, a resident received their medication as ordered during their respite stay, and ensure administration of a sedative/hypnotic medication as ordered for 3 residents (Residents G, C, and 40).
Failed to ensure a clinical rationale was provided for a decline of a gradual dose reduction of an antidepressant and antianxiety medication for 2 of 5 residents reviewed for unnecessary medications (Residents 26 and 30).
Failed to maintain infection control practices by not donning personal protective equipment (PPE) while providing activities of daily living care for 1 of 1 randomly observed resident (Resident 299).
Report Facts
Survey dates: 2025-02-11 to 2025-02-14
Census: 51
Total capacity: 66
Deficiency severity count: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin Meier | Executive Director | Signed the report |
| LPN 2 | Licensed Practical Nurse | Named in medication administration and pain management findings |
| Director of Health Services | Interviewed regarding multiple deficiencies including medication administration, tube feeding, oxygen tubing, pain management, and infection control | |
| Assistant Director of Health Services | Interviewed regarding medication administration and oxygen tubing | |
| Certified Resident Care Associate (CRCA) | Observed providing care without proper PPE |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00440151 completed on August 9, 2024.
Complaint Details
Investigation of Complaint IN00440151 completed with paper compliance.
Findings
The Springs of Richmond was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Investigation of Complaint IN00440151.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Aug 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440151 regarding allegations related to pressure ulcer care and treatment.
Complaint Details
Complaint IN00440151 was substantiated with federal/state deficiency related to pressure ulcer care cited at F686.
Findings
The facility failed to ensure that one of three residents reviewed for pressure ulcers had routine and timely wound assessments, including measurements, conducted on a weekly or more frequent basis, and proper documentation was lacking. Resident B's wound assessments and documentation were incomplete and delayed, with inadequate communication to the attending physician until weeks after admission.
Deficiencies (1)
Failure to ensure routine and timely wound assessments and documentation for pressure ulcers as per professional standards.
Report Facts
Census: 62
SNF/NF beds: 7
SNF beds: 41
Residential beds: 14
Medicare residents: 37
Medicaid residents: 7
Other payor residents: 4
Wound measurements: 2.5
Wound measurements: 1.8
Wound measurements: 0.2
Wound measurements: 1
Wound measurements: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amie Groce | RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00436445 completed on June 26, 2024.
Complaint Details
Investigation of Complaint IN00436445 completed on June 26, 2024; paper compliance was reviewed and found compliant.
Findings
The Springs of Richmond was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Investigation of Complaint IN00436445.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: Jun 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436445 regarding federal and state deficiencies related to nutrition and hydration documentation.
Complaint Details
Complaint IN00436445 was substantiated with federal and state deficiencies cited related to nutrition and hydration documentation failures.
Findings
The facility failed to routinely document meal intakes for 3 of 3 residents reviewed for nutritional concerns, specifically Residents B, C, and D. Multiple dates were identified where meal documentation was missing, and the facility's Registered Dietitian noted concerns about weight loss, poor appetite, and skin integrity related to nutrition.
Deficiencies (1)
Failed to routinely document meal intakes for 3 of 3 residents reviewed for nutritional concerns.
Report Facts
Census: 65
Residents reviewed for nutritional concerns: 3
Meal documentation missing dates for Resident B: 9
Meal documentation missing dates for Resident C: 6
Meal documentation missing dates for Resident D: 5
Weight loss: 21
Weight gain: 10
Weight gain: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin Meier | Executive Director | Signed the report |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 21, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00425452 and IN00433665 completed on May 17, 2024.
Complaint Details
Investigation of Complaints IN00425452 and IN00433665; paper compliance confirmed.
Findings
The Springs of Richmond was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Investigation of Complaints IN00425452 and IN00433665.
Inspection Report
Complaint Investigation
Census: 45
Capacity: 57
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00435007 and IN00435049 at The Springs of Richmond facility.
Complaint Details
Investigation of Complaints IN00435007 and IN00435049 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00435007 and IN00435049 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 7
Census Bed Type - SNF: 38
Census Bed Type - Residential: 12
Total Capacity: 57
Census Payor Type - Medicare: 35
Census Payor Type - Medicaid: 7
Census Payor Type - Other: 3
Total Census: 45
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 4
Date: May 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00425452, IN00431057, IN00433045, and IN00433665 at Springs of Richmond.
Complaint Details
Complaint IN00425452 was substantiated with deficiencies cited at F558 related to call light response. Complaint IN00433665 was substantiated with deficiencies cited at F656, F677, and F812 related to care planning, ADL care, and food sanitation. Complaints IN00431057 and IN00433045 had no deficiencies related to the allegations.
Findings
The facility was found deficient in responding promptly to call light requests for assistance, developing and implementing care plans for bathing preferences, providing routine bathing and hygiene care for dependent residents, and maintaining sanitary food procurement, storage, and preparation practices. Some complaints were substantiated with deficiencies cited, while others were not.
Deficiencies (4)
Failed to promptly respond to call light requests for assistance for 2 of 3 residents reviewed.
Failed to develop and implement a care plan for bathing preferences for 1 of 1 residents reviewed.
Failed to ensure a dependent resident received bathing and hygiene care and services on a routine basis for 1 of 5 residents reviewed.
Failed to ensure food products held in the refrigerator for re-use were properly dated, bin covers for flour and sugar containers were closed, refrigerator and freezer temperatures were routinely documented, and manual ware washing logs were documented routinely.
Report Facts
Residents present: 64
Residents reviewed for call light response: 3
Residents affected by call light deficiency: 2
Residents reviewed for bathing preferences: 1
Residents reviewed for ADL care: 5
Residents affected by bathing and hygiene deficiency: 1
Total residents: 65
Inspection Report
Re-Inspection
Census: 58
Capacity: 70
Deficiencies: 0
Date: Jan 16, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure survey conducted on 12/14/23 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Springs of Richmond was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 70
Census: 58
Inspection Report
Life Safety
Census: 57
Capacity: 70
Deficiencies: 4
Date: Dec 14, 2023
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 NFPA 101 Life Safety Code requirements.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies related to corridor means of egress obstructions, delayed egress locking arrangements, corridor door closure and latching, and HVAC combustion air intake for fuel-fired equipment.
Deficiencies (4)
Failed to ensure 3 of 3 corridor means of egresses were continuously maintained free of obstructions due to PPE carts without wheels blocking hallways outside Resident Rooms 205, 227, and 207.
Failed to ensure 1 of 1 delayed egress locking arrangements in the 600 hall was installed in accordance with LSC; the Therapy Exit door's delayed egress did not release the lock as required.
Failed to ensure 1 of over 30 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke; corridor door to Resident Room #234 failed to close and latch positively.
Failed to ensure 1 of 1 laundry rooms was provided with intake combustion air from the outside for rooms containing fuel fired equipment; the automatic louvers for the dryer area did not open when dryers were running.
Report Facts
Certified beds: 70
Census: 57
Residents affected: 28
Residents affected: 10
Corridor doors inspected: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Interviewed regarding PPE carts without wheels, delayed egress locking, corridor door deficiencies, and HVAC issues; acknowledged findings during survey and exit conference. | |
| Facilities Management Support | Participated in facility tour and exit conference acknowledging findings. |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 5
Date: Dec 4, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00422649. The complaint investigation found no deficiencies related to the allegations.
Complaint Details
Complaint IN00422649 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found to have several deficiencies including failure to complete grievance process for a resident, inadequate nail care for a dependent resident, improper storage of a nebulizer mask, failure to provide outdoor activities for a resident with dementia, and failure to complete an elopement assessment for a resident with elopement risk. Plans of correction were submitted for all findings.
Deficiencies (5)
Failed to complete a grievance for Resident 30 and lacked a process for anonymous grievances.
Failed to provide nail care for a dependent resident (Resident 3).
Failed to store a nebulizer mask in a sanitary manner for infection control (Resident 17).
Failed to provide outdoor activities on a regular basis per the resident's preference for dementia care (Resident 8).
Failed to complete an elopement assessment for a resident with elopement behaviors (Resident 8).
Report Facts
Survey dates: 6
Census Bed Type: 56
Census Payor Type: 44
Deficiency count: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
Paper compliance review related to the Recertification and State Licensure Survey completed on December 4, 2023.
Findings
The Springs of Richmond was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418846.
Complaint Details
Complaint IN00418846 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00418846 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 7
Census Bed Type - SNF: 22
Census Total: 29
Census Payor Type - Medicare: 22
Census Payor Type - Medicaid: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00410948 completed on July 27, 2023.
Findings
The Springs of Richmond was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Jul 25, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00406226, IN00410948, and IN00412726 at The Springs of Richmond facility.
Complaint Details
Complaint IN00406226 had no deficiencies related to the allegations. Complaint IN00410948 had federal/state deficiencies cited at F622 and F684 related to transfer/discharge documentation and quality of care regarding anticoagulant labwork. Complaint IN00412726 had no deficiencies related to the allegations.
Findings
The facility was found deficient related to complaint IN00410948 for failure to ensure appropriate documentation for transfer and discharge rights for 2 of 3 residents reviewed, and failure to ensure physician-ordered labwork was conducted as ordered for 1 resident on anticoagulant therapy. No deficiencies were cited for the other complaints.
Deficiencies (2)
Failure to ensure 2 of 3 residents had appropriate documentation for notification of the State's and facility's bed hold policy when transferred emergently or non-emergently.
Failure to ensure physician-ordered labwork was conducted as ordered for 1 resident reviewed for anticoagulant therapy.
Report Facts
Residents reviewed for transfer and discharge rights: 3
Residents reviewed for anticoagulant therapy labwork: 1
Survey dates: July 25, 26, and 27, 2023
Census by bed type: 51
Census by payor type: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Roos | Clinical Support RN BSN | Signed the report and provided policy information |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 27, 2023
Visit Reason
The document addresses paper compliance related to the investigation of complaints IN00400634 and IN00401243 completed on February 13, 2023.
Complaint Details
The document pertains to the investigation of complaints IN00400634 and IN00401243 and confirms compliance with regulatory requirements.
Findings
The Springs of Richmond was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00403710.
Complaint Details
Complaint IN00403710 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census Bed Type Total: 67
Census Bed Type SNF/NF: 6
Census Bed Type SNF: 43
Census Bed Type Residential: 18
Census Payor Type Medicare: 43
Census Payor Type Medicaid: 6
Census Payor Type Other: 5
Census Payor Type Total: 54
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 20, 2023
Visit Reason
The document addresses paper compliance related to the investigation of multiple complaints (IN00393842, IN00395478, IN00396680, and IN00398651) completed on January 10, 2023.
Complaint Details
The visit was related to complaint investigations identified by complaint numbers IN00393842, IN00395478, IN00396680, and IN00398651. Compliance was found in the paper review.
Findings
The Springs of Richmond was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Feb 13, 2023
Visit Reason
This visit was for the investigation of three complaints (IN00400400, IN00400634, and IN00401243) regarding quality of care and pressure ulcer prevention at the facility.
Complaint Details
Complaint IN00400400 was unsubstantiated due to lack of evidence. Complaints IN00400634 and IN00401243 were substantiated with federal/state deficiencies cited at F686 and F684 respectively.
Findings
The facility was found to have deficiencies related to failure to provide prescribed antibiotic treatment for a urinary tract infection to one resident and failure to provide a pressure ulcer reducing wheelchair cushion for another resident with an unstageable pressure ulcer. Both residents were affected by the deficient practices but with no adverse effects noted.
Deficiencies (2)
Failed to provide an antibiotic as prescribed by the physician to treat a resident's urinary tract infection (Resident B).
Failed to provide pressure ulcer reducing wheelchair cushion as ordered by the physician for a resident with an unstageable pressure ulcer (Resident E).
Report Facts
Census: 36
Missed antibiotic doses: 11
Pressure ulcer size: 4
Pressure ulcer size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Allen | Director of Nursing | Signed the report and mentioned as Director of Nursing |
| Director of Health Services (DHS) | Interviewed regarding delay in antibiotic administration and concerns about UTI | |
| LPN 1 | Licensed Practical Nurse | Verified Resident E did not have a pressure reducing cushion in wheelchair |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 55
Deficiencies: 3
Date: Jan 9, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00393842, IN00395478, IN00396007, IN00396680, and IN00398651) at Springs of Richmond.
Complaint Details
Complaints IN00393842, IN00395478, IN00396680, and IN00398651 were substantiated with federal/state deficiencies cited at F554 and F676. Complaint IN00396007 was unsubstantiated.
Findings
The facility was found deficient in several areas including failure to ensure clinical appropriateness for resident self-administration of medications, failure to assist dependent residents with bathing and nail care, and failure to ensure medications were administered by qualified personnel. Several complaints were substantiated with related federal/state deficiencies cited.
Deficiencies (3)
Facility failed to ensure a resident was determined clinically appropriate to self-administer medications.
Facility failed to assist dependent residents with bathing tasks and failed to assist a dependent resident with nail care.
Facility failed to ensure medications ordered were administered by qualified personnel.
Report Facts
Residents observed for medication administration: 5
Residents reviewed for activities of daily living: 4
Residents reviewed for medication administration: 5
Census by payor type: 36
Census by payor type: 3
Total census: 39
Total licensed capacity: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Lacey | Interim Executive Director | Signed the report and mentioned in interview regarding medication administration incident. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 9, 2022
Visit Reason
Paper compliance to the Post Survey Revisit (PSR) to the Recertification, State Licensure Survey and Investigation of Complaint IN00386195 and IN00390959 completed on November 9, 2022, following previous surveys and complaint investigations.
Findings
The Springs of Richmond was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the PSR to the Recertification, State Licensure Survey and Investigation of Complaint IN00386195 and IN00390959 completed on November 9, 2022.
Inspection Report
Re-Inspection
Census: 58
Capacity: 70
Deficiencies: 0
Date: Nov 28, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure survey conducted on 10/25/22 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Springs of Richmond was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinkled with a fire alarm system and smoke detectors in all resident sleeping rooms.
Report Facts
Facility capacity: 70
Census: 58
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 1
Date: Nov 9, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on September 30, 2022, including PSRs to the Investigation of Complaints IN00386195 and IN00390959 and the State Residential Licensure Survey completed on September 30, 2022.
Complaint Details
This visit included a PSR to the Investigation of Complaint IN00386195 and Complaint IN00390959, both of which were found Not Corrected.
Findings
The facility failed to obtain a physician order for treatment for a pressure area upon re-admission, provide treatment for a pressure area, and complete accurate audits for pressure area treatments for one resident (Resident M). The deficiency cited on 9/30/2022 was not corrected, and the facility failed to implement a systemic plan of correction to prevent recurrence.
Deficiencies (1)
Failed to obtain a physician order for treatment for a pressure area upon re-admission, provide treatment for a pressure area, and complete accurate audits for pressure area treatments for Resident M.
Report Facts
Census Bed Type - SNF: 35
Census Bed Type - NF: 3
Census Bed Type - Residential: 18
Total Census: 56
Census Payor Type - Medicare: 35
Census Payor Type - Medicaid: 3
Total Census Payor: 38
Pressure area measurements: 15
Pressure area measurements: 11
Pressure area measurements: 11
Pressure area measurements: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marilyn Alberson | Executive Director | Signed the report |
| Director of Health Services | Interviewed regarding pressure area treatment and facility policies |
Inspection Report
Life Safety
Census: 58
Capacity: 70
Deficiencies: 5
Date: Oct 25, 2022
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. Deficiencies included failure to ensure self-closing devices on hazardous area doors, lack of access to cooktop shutoff switch, missing sprinkler escutcheons, improper storage of spare sprinklers, and use of an extension cord as a substitute for fixed wiring.
Deficiencies (5)
Failed to ensure 2 hazardous area doors had properly working self-closing devices, including the SPA Room and Administrative Office Suite corridor doors.
Failed to ensure staff had access to the shutoff switch for 1 cooktop in the therapy area.
Failed to maintain ceiling construction by missing escutcheons on 2 of 12 sprinkler heads in the Therapy Area.
Failed to provide spare sprinklers properly stored in protected slots in the sprinkler cabinet; some sprinkler heads were loose.
Failed to ensure flexible cords were not used as a substitute for fixed wiring; an extension cord was used to power a piano in the entrance lobby.
Report Facts
Certified beds: 70
Census: 58
Hazardous area doors deficient: 2
Sprinkler heads missing escutcheons: 2
Spare sprinkler cabinets: 6
Sprinkler heads not in protected slots: 6
Residents potentially affected by cooktop issue: 6
Staff and residents potentially affected by extension cord issue: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marilyn Alberson | Executive Director | Present at exit conference and named in relation to findings and plan of correction |
| Director of Plant Operations | Interviewed and involved in findings related to hazardous doors, cooktop shutoff, sprinkler escutcheons, spare sprinkler storage, and extension cord use |
Inspection Report
Recertification
Census: 11
Deficiencies: 10
Date: Sep 30, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00386195 and IN00390959.
Complaint Details
Complaint IN00386195 was substantiated with deficiencies cited at F-684, F-686, and F-689. Complaint IN00390959 was substantiated with deficiencies cited at F-684 and F-686.
Findings
The facility was found to have multiple deficiencies including failure to provide fresh water and meal assistance, inaccurate assessments, inadequate ADL care, skin integrity issues including pressure ulcers, failure to implement fall interventions, improper catheter care, oxygen therapy issues, and infection control lapses.
Deficiencies (10)
Failed to provide fresh water daily and assist a legally blind resident with meal set up, a divided plate and built up utensils.
Failed to accurately document use of anticoagulants on the Minimum Data Set (MDS) assessments for 2 residents.
Failed to ensure dependent residents received showers and nail care.
Failed to ensure dependent resident received care to prevent skin alterations, apply ace wraps per orders, and conduct complete wound assessments.
Failed to ensure hearing aids were placed per plan of care for a resident who was hard of hearing.
Failed to implement pressure relieving devices and follow physician orders for pressure ulcers for 4 residents.
Failed to ensure fall interventions were implemented per plan of care for 2 residents.
Failed to maintain urinary catheter bag free of contact with the floor for 1 resident.
Failed to ensure oxygen was in place per physician orders, humidifier bottle had water, and CPAP device was utilized for 3 residents.
Failed to ensure infection control practices were maintained during dressing change and cleaning of vital signs machine between residents.
Report Facts
Census: 11
Survey dates: September 25 through September 30, 2022
Pressure ulcer size: 3
Pressure ulcer size: 3.5
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