Springhurst Health Campus

Inspectors wroteBased on interview and record review, the facility failed to correctly transcribe the hospital's discharge orders for 1 of 3 residents reviewed for accuracy of physician orders for a newly admitted resident. This deficient practice resulted in a resident not having a diagnosis of diabetes identified and not receiving his hospital discharged ordered insulin for five (5) days, which contributed to the resident having elevated (high) blood glucose, diminished cognitive levels, lethargy and being sent out to the local hospital. The resident was sent out to the local hospital on 2-13-26, at the request of the family. He was subsequently admitted to the local hospital the same date for altered mental status, possibly related to dehydration, infection or diabetic ketoacidosis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff to provide activities of daily living (ADL) care, skin care treatments, and maintain residents' dignity. This deficient practice had the potential to affect 61 of 61 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist dependent residents with shaving per preference and provide activities of daily living (ADL) care in a timely manner for 4 of 7 residents reviewed for activities of daily living. (Resident E, Resident G, Resident L, and Resident J)

Inspectors wrote2. The clinical record for Resident F was reviewed on 6/11/25 at 10:30 a.m. His diagnoses included, but were not limited to, Parkinson's disease. An interview was conducted with Family Member 4 on 6/11/25 at 10:38 a.m. She indicated there was an incident involving Resident F and CRCA (Certified Resident Care Assistant) 15 in March 2025 in his room. Resident F had bowel issues. It wasn't a happy situation, and CRCA 16 had to clean it up. CRCA 16 said it was gross right in front of him. They filed a grievance about it. Family Member 4 received a call back afterwards, stating the facility would be doing more staff training. The grievance log for the past six months was provided by Clinical Support on 6/12/25 at 10:48 a.m. There were only two grievances associated with Resident F, both dated 3/6/25, and both filed by Family Member 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for 1 of 1 resident reviewed for call light accessibility. (Resident 218)

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately report an allegation of abuse to the ED (Executive Director) and IDOH (Indiana Department of Health) for 2 of 2 residents reviewed for abuse. (Resident D and Resident H)

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and initiate a thorough investigation into an alleged violation of abuse for 2 of 2 residents reviewed for abuse. (Residents D and H)

Inspectors wroteBased on interview and record review, the facility failed to timely transmit a Quarterly Minimum Data Set (MDS) assessment for 1 of 9 residents reviewed for MDS Assessments. (Resident 21)

Inspectors wrote3. The clinical record for Resident Q was reviewed on 6/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, overactive bladder and urinary tract infection. An interview and observation were conducted with Family Member 7 on 6/11/25 at 11:05 a.m. She indicated Resident Q had a history of UTIs (urinary tract infections.) During her most recent care plan meeting a couple of weeks ago, they discussed Resident Q having a possible allergy to Bactrim, an antibiotic medication used to treat UTIs. The staff at the care plan meeting said they would chart it, but she wasn't sure what happened, because she was just prescribed it again a couple of days ago, and Resident Q's lips swelled up, like they did in April 2025, when she was prescribed it. At this time, Family Member 7 displayed two photographs on her cell phone. [...]

Inspectors wroteBased on interview, observation, and record review, 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. (Resident E)

Inspectors wroteBased on interview and record review, the facility failed to follow hospital discharge orders to discontinue medication upon readmission for 1 of 4 residents reviewed for quality of care. (Resident J) The clinical record for Resident J was reviewed on 6/12/25 at 10:04 a.m. The diagnoses included, but were not limited to, anemia and atrial fibrillation. During an interview with Resident J on 6/11/25 at 12:51 p.m., Resident J indicated she had just returned from the hospital yesterday after having blood loss and thought she had been told they were going to hold all of her blood thinners for a while. The admission Minimum Data Set (MDS) assessment, dated 5/9/25, indicated Resident J was cognitively intact. The hospital Discharge summary, dated [DATE], was provided by MDS Support on 6/12/25 at 12:57 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote a resident's dignity by telling Resident H to utilize 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.

Inspectors wroteBased on interview, and record review, the facility failed to provide showers as scheduled for 2 of 4 residents reviewed for activities of daily living. (Residents K and B)

Inspectors wroteBased on interview and record review, the facility failed to provide Resident 207 with a Notification of Medicare Non-Coverage (NOMNC) at least two calendar days prior to discharge from Medicare Part A services for 1 of 3 beneficiary notices reviewed.

Inspectors wroteBased on record review and interview, the facility failed to provide written bed hold information for 1 of 2 residents reviewed for hospitalization. (Resident 15)

Inspectors wroteBased on interview and record review the facility failed to complete a care plan meeting for 1 of 1 resident's reviewed for care plan meetings (Resident 43).

Inspectors wroteBased on observation, interview and record review the facility failed to provide showers as scheduled for dependent residents for 2 of 2 reviewed for Activities Of Daily Living (ADL) ( Resident 30 and Resident 9).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure collaboration with a hospice provider regarding coordination of care related to laboratory work, medication form changes, wound assessments, and Registered Dietitian (RD) recommendations for 1 of 1 resident reviewed for hospice services (Resident 17), 1 of 5 residents reviewed for pressure ulcers (Resident 22), and 1 of 1 resident reviewed for nutrition (Resident 26). The facility also failed to ensure a device was in place, per physician orders, in regard to limited range of motion (ROM) for 1 of 1 resident reviewed for impaired mobility (Resident 22).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure weekly measurements were conducted of pressure ulcers, provide treatment as ordered by the physician, and ensure a resident with a history of pressure ulcers didn't stay in the same position for an extended period of time for 2 of 5 residents reviewed for pressure ulcers. (Resident 17 and Resident 22)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall interventions were in place per the care plan and ensure a fall follow-up included completed neurological checks for 3 of 4 residents reviewed for accidents. (Resident 17, 31, and 9)

Inspectors wroteBased on interview and record review, the facility failed to follow up with a Registered Dietitian (RD) recommendations for a supplement for a resident who experienced significant weight loss for 1 of 1 resident reviewed for nutrition. (Resident 26)

Inspectors wroteBased on observation, interview and record review the facility failed to store oxygen nasal cannula and C- PAP mask in a bag for infection control purposes and failed to date oxygen tubing for 2 of 2 residents reviewed for respiratory care (Resident 45 and Resident 163).

Inspectors wroteBased on interview and record review, the facility failed to ensure a pharmacy recommendation was followed up with timely for 2 of 5 residents reviewed for unnecessary medications. (Resident 31 and Resident 9)

Inspectors wroteBased on observation, interview and record review the facility failed to provide routine dental services for a resident who had missing or broken teeth and difficulty chewing, for 1 of 2 residents reviewed for dental status (Resident 15).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not handled by bare hands during a medication administration observation. This affected 1 of 3 residents observed for a medication pass. (Resident 45)