Inspection Report Summary
The most recent inspection on May 30, 2025, found the facility deficient in areas including resident hydration, assistance with eating, medication allergy management, oxygen orders, and kitchen sanitation. Earlier inspections showed a pattern of deficiencies related to resident care documentation, medication administration errors, and sanitation issues, as well as Life Safety Code concerns such as egress door locking and sprinkler system maintenance. Complaint investigations were mostly unsubstantiated, except for one substantiated complaint involving medication errors and another related to sanitation and pest control that resulted in federal deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges in care and sanitation with some recurring issues, indicating a need for continued attention to compliance.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
121% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 51
Capacity: 51
Deficiencies: 5
May 30, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00455673 and IN00454984.
Findings
The facility was found deficient in several areas including failure to ensure availability of fluids at bedside for a resident, failure to provide assistance with eating, failure to timely address a resident's documented medication allergy, failure to ensure a resident had an oxygen order, and failure to maintain the kitchen in a sanitary manner with ice buildup in the walk-in freezer.
Complaint Details
Complaint IN00455673 and Complaint IN00454984 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure availability of fluids at the bedside for Resident 35. | SS=D |
| Failed to provide assistance with eating for Resident 35. | SS=D |
| Failed to timely address a resident's documented medication allergy for Resident 40. | SS=D |
| Failed to ensure Resident 28 had a physician's order for oxygen. | SS=D |
| Failed to maintain the kitchen in a sanitary manner with black substance on dish sink walls and ice buildup in walk-in freezer. | SS=F |
Report Facts
Census: 51
Total Capacity: 51
Dates of Survey: May 27, 28, 29, and 30, 2025
Residents reviewed for ADLs: 3
Residents reviewed for respiratory care: 2
Residents reviewed for medication allergies: 1
Residents affected by kitchen sanitation issue: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Merry Goodwin | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Nursing | Director of Nursing | Interviewed regarding fluid availability, feeding assistance, medication allergy, and oxygen order deficiencies |
| Dietary Manager | Dietary Manager | Interviewed and responsible for kitchen sanitation and freezer maintenance |
| Director of Maintenance | Director of Maintenance | Interviewed regarding kitchen maintenance and freezer ice buildup |
Inspection Report
Annual Inspection
Deficiencies: 0
May 30, 2025
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure Survey completed on May 30, 2025.
Findings
Willows 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 for the Annual Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 87
Deficiencies: 0
Mar 21, 2025
Visit Reason
An investigation of Complaint Number IN00455669 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The complaint was found to be unsubstantiated. The facility 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.
Complaint Details
Complaint Number IN00455669 was unsubstantiated.
Report Facts
Facility capacity: 87
Census: 53
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Mar 6, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00454868.
Findings
No deficiencies related to the allegations are cited. Willows of Richmond was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the Investigation of Complaint IN00454868.
Complaint Details
Complaint IN00454868 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF: 51
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 40
Census Payor Type Other: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 3, 2025
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00450460 completed on January 3, 2025.
Findings
Willows 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 complaint investigation.
Complaint Details
Complaint IN00450460 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 1
Jan 2, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00450200, IN00450346, and IN00450460. The investigation focused on allegations related to medication administration errors.
Findings
The facility failed to ensure that one of three residents reviewed (Resident F) received medications as ordered by the physician, specifically a medication error involving alprazolam (Xanax) dosing after hospital readmission. The facility did not properly transcribe the medication order upon the resident's return, resulting in missed doses and subsequent health complications.
Complaint Details
Complaint IN00450460 was substantiated with a federal/state deficiency cited at F760 related to medication errors. Complaints IN00450200 and IN00450346 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident F received medications as ordered by the physician, specifically alprazolam (Xanax) dosing errors after hospital readmission. | SS=D |
Report Facts
Census: 55
Total Capacity: 55
Medicare Residents: 4
Medicaid Residents: 40
Other Payor Residents: 11
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Oct 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444874.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00444874 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 52
Total Capacity: 52
Payor Type Census: 1
Payor Type Census: 43
Payor Type Census: 8
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 15, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00435418 and IN00435596 completed on June 18, 2024.
Findings
Willows 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 review to the Complaint Survey.
Complaint Details
The visit was related to complaint investigations IN00435418 and IN00435596, with findings indicating compliance.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 1
Jun 18, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00435418 and IN00435596 regarding resident records and documentation.
Findings
The facility failed to maintain accurately documented resident records for oral hygiene and meal intakes for 3 residents reviewed (Residents B, C, and D). Documentation inconsistencies and incomplete records were found in the electronic health record system for meal intakes and oral care provision.
Complaint Details
This visit was triggered by complaints IN00435418 and IN00435596. Both complaints resulted in federal/state deficiencies cited at F842 related to resident records and documentation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain resident records that were accurately documented for oral hygiene and meal intakes for 3 residents. | SS=D |
Report Facts
Census: 56
Total Capacity: 56
Medicare Census: 5
Medicaid Census: 44
Other Payor Census: 7
Survey Dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Merry Goodwin | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Life Safety
Census: 54
Capacity: 87
Deficiencies: 0
May 30, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/30/24 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Willows of Richmond was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinkled except for one detached all metal storage garage.
Report Facts
Facility capacity: 87
Census: 54
Inspection Report
Renewal
Deficiencies: 0
May 15, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Recertification and State Licensure of the facility.
Findings
Willows 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 review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 51
Capacity: 87
Deficiencies: 2
Apr 30, 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 NFPA 101, Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with egress door locking mechanisms and hazardous area door self-closing devices. The facility was otherwise compliant with Emergency Preparedness Requirements.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress through all exits was readily accessible; front entrance door was magnetically locked without posted exit code. | SS=E |
| Failed to ensure hazardous area doors, such as storage rooms, were provided with properly working self-closing devices. | SS=E |
Report Facts
Certified beds: 87
Census: 51
Combustible cardboard boxes: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Merry Goodwin | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed regarding egress door locking and hazardous area door deficiencies |
Inspection Report
Annual Inspection
Census: 50
Capacity: 50
Deficiencies: 5
Apr 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from April 14 to April 19, 2024.
Findings
The facility was found deficient in several areas including timely completion and accuracy of Minimum Data Set (MDS) assessments, development and implementation of comprehensive care plans, assessment and documentation of skin conditions, and implementation of physician orders for orthotic devices. Corrective actions and monitoring plans were outlined for each deficiency.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to timely complete and entry tracking record for 1 of 19 residents reviewed for MDS timeliness (Resident 154). | SS=D |
| Failed to accurately encode MDS data for 5 of 19 residents, including smoking status, GDR dates, prognosis, discharge status, and use of mechanical ventilation. | SS=E |
| Failed to ensure care plans were developed for a resident using a bipap machine and insulin (Resident 103), for seizures and anti-seizure medication (Resident 41), and for pain (Resident 5). | SS=D |
| Failed to assess and document bruising on 1 of 2 residents reviewed for general skin conditions (Resident 29). | SS=D |
| Failed to implement a physician order for a carrot splint for a resident's left hand contracture (Resident 13). | SS=D |
Report Facts
Survey dates: 6
Residents reviewed for MDS timeliness: 19
Residents reviewed for MDS accuracy: 19
Residents reviewed for care plans: 21
Residents reviewed for skin conditions: 2
Residents with limited ROM reviewed: 1
Facility census: 50
Facility total capacity: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Merry Goodwin | Health Facility Administrator | Signed the inspection report |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 6, 2024
Visit Reason
Paper compliance review to the Complaint Investigation completed on January 18, 2024.
Findings
Willows 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 review to the Complaint Survey.
Complaint Details
This visit was a paper compliance review related to a complaint investigation completed on January 18, 2024. The facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 4
Jan 18, 2024
Visit Reason
This visit was for the investigation of Complaint IN00424062, which involved federal deficiencies related to allegations cited at F-584, F-812, F-814, and F-925.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean and sanitary dining room with food debris and cockroaches observed, failure to maintain the kitchen in a sanitary manner with cockroach infestation and disrepair of baseboards, failure to properly dispose of garbage with dumpster lids open and trash around dumpsters, and failure to maintain an effective pest control program resulting in ongoing cockroach presence throughout the facility.
Complaint Details
Complaint IN00424062 was substantiated with federal deficiencies cited at F-584, F-812, F-814, and F-925 related to sanitation, food safety, garbage disposal, and pest control issues.
Severity Breakdown
SS=D: 2
SS=F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain the dining room in a clean and sanitary manner with food debris and cockroaches observed. | SS=D |
| Failed to procure, store, prepare, and serve food in a sanitary manner; kitchen had cockroach infestation and disrepair of baseboards. | SS=F |
| Failed to properly dispose of garbage and refuse; dumpster lids were open and area around dumpsters was not clean. | SS=D |
| Failed to maintain an effective pest control program; cockroaches observed throughout the facility including resident rooms. | SS=F |
Report Facts
Residents present: 51
Total licensed capacity: 51
Residents affected by dining room sanitation issue: 6
Residents potentially affected by kitchen sanitation and pest issues: 50
Dumpster lids open: 4
Cockroach trap counts: 25
Pest control treatment frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Merry Goodwin | Health Facility Administrator | Signed report and involved in interviews |
| Assistant Director Of Nursing | Assistant Director Of Nursing | Interviewed regarding dining room sanitation and food debris |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation, pest control, and baseboard disrepair |
| Owner of the pest control company | Interviewed regarding pest control issues and treatment | |
| Administrator | Administrator | Interviewed regarding facility census, sanitation policies, and pest control |
| Maintenance Director | Maintenance Director | Responsible for auditing and repairing baseboards and pest control monitoring |
| CNA 1 | Certified Nursing Assistant | Interviewed confirming cockroach sightings |
| CNA 2 | Certified Nursing Assistant | Interviewed confirming cockroach sightings |
| CNA 3 | Certified Nursing Assistant | Interviewed confirming cockroach sightings |
| CNA 4 | Certified Nursing Assistant | Interviewed confirming cockroach sightings |
Inspection Report
Life Safety
Deficiencies: 0
Jun 29, 2023
Visit Reason
The visit was a Post Survey Revisit (PSR) related to the Life Safety Code Recertification and State Licensure Survey that exited on 04/05/23, completed on 06/29/23.
Findings
Heritage House 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.
Inspection Report
Re-Inspection
Census: 40
Capacity: 87
Deficiencies: 1
Jun 7, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/05/23 was performed to assess compliance with fire safety regulations.
Findings
The facility was found not in compliance with fire safety requirements due to unsealed gaps around sprinkler heads caused by dropped sprinkler heads through the ceiling, which could delay sprinkler activation. The Maintenance Director acknowledged the issue and a plan of correction was in place involving replacement of sprinkler heads and ongoing inspections.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain ceiling construction in 1 of 1 smoke compartment; unsealed gaps around sprinkler heads due to dropped sprinkler heads through the ceiling. | SS=E |
Report Facts
Facility capacity: 87
Census: 40
Sprinkler heads affected: 2
Inspection date: Apr 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Merry Goodwin | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed regarding sprinkler head deficiencies and plan of correction |
Inspection Report
Renewal
Deficiencies: 0
May 3, 2023
Visit Reason
The inspection was a paper compliance review related to the Recertification and State Licensure of Heritage House of Richmond.
Findings
Heritage House 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 review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 46
Capacity: 87
Deficiencies: 5
Apr 5, 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 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements including issues with egress door locking arrangements, staff training on kitchen fire suppression system, maintenance of sprinkler system ceiling construction, smoke detection in activity areas, and improper use of power strips in patient care vicinities.
Severity Breakdown
SS=F: 1
SS=E: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Means of egress doors were magnetically locked with a code not posted in a manner accessible without special knowledge. | SS=F |
| Staff were not instructed in the use of the UL 300 hood fire suppression system in the kitchen. | SS=E |
| Ceiling construction in a smoke compartment was not maintained properly, with sprinkler heads dropped through the ceiling creating unsealed gaps. | SS=E |
| An activities area with a pass-through window greater than 20 square inches was not protected by an electrically supervised automatic smoke detection device. | SS=E |
| Power strips in a patient care vicinity did not meet UL rating requirements (1363A or 60601-1). | SS=E |
Report Facts
Certified beds: 87
Census: 46
Exit doors magnetically locked: 6
Sprinkler heads dropped: 2
Residents affected by power strip deficiency: 2
Residents in dining room affected by kitchen fire suppression deficiency: 15
Residents in smoke compartment affected by activities area deficiency: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged findings related to exit door locking, kitchen fire suppression training, sprinkler head issues, smoke detection, and power strip deficiencies. | |
| Lunch and Dinner Cook | Failed to identify location of hood suppression pull station and was unaware of proper response to grease fire. |
Inspection Report
Renewal
Census: 45
Capacity: 45
Deficiencies: 4
Mar 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 12 to March 17, 2023.
Findings
The facility was found deficient in several areas including failure to keep a resident's call light and water within reach, inadequate nail care for dependent residents, failure to post daily nurse staffing information for one day, and failure to ensure timely medication regimen reviews and documentation of clinical contraindications for gradual dose reductions for certain residents.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to keep a resident's call light and water within reach for 1 of 1 residents reviewed for accommodation of needs. | SS=D |
| Failed to assist dependent residents with nail care to ensure fingernails were kept short, clean and free of rough edges for 3 of 4 residents reviewed for Activities of Daily Living. | SS=D |
| Failed to post the nursing daily staffing sheet for 1 of 6 days reviewed during the survey. | SS=D |
| Failed to ensure medication recommendations from pharmacy were received and conveyed timely to the attending physician and failed to document clinical contraindications for refusing gradual dose reduction for 3 of 5 residents reviewed for medications. | SS=D |
Report Facts
Survey dates: 6
Resident census: 45
Total capacity: 45
Medicare residents: 7
Medicaid residents: 35
Other payor residents: 3
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