Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springhurst Health Campus during CMS and state inspections, most recent first.
A resident with type 2 DM, dementia, and other acute conditions was admitted from the hospital with discharge orders for Lantus insulin twice daily and BG monitoring before meals. Multiple staff, including the DHS, MDS staff, an NP, and nurses, reviewed the discharge paperwork but failed to identify and transcribe the DM diagnosis and insulin/BG monitoring orders into the EHR at admission. The omission was discovered days later during a care planning meeting when a family member asked about BG levels, by which time the resident had received only one insulin injection and had persistently elevated BG readings, along with diminished cognition and lethargy, leading to transfer and admission to a hospital where uncontrolled DM and altered mental status were documented.
The facility did not maintain adequate nursing staff, leading to delays in ADL care, skin care treatments, and incontinence care. Residents and family members reported long wait times for assistance, and staff described frequent shortages, missed care tasks, and unresponsive management. Documentation and Resident Council minutes confirmed ongoing concerns about short staffing and its impact on resident dignity and care.
Several dependent residents did not receive timely assistance with ADLs, including shaving and toileting. One resident was not helped with shaving for over a week despite his preferences, while another waited over two weeks for shaving assistance despite repeated requests. Two residents experienced long waits for toileting help, resulting in incontinence and embarrassment. Staff interviews confirmed challenges in meeting residents' ADL needs.
A resident with dementia, orthostatic hypotension, and muscle weakness was observed multiple times without access to a call light while in a wheelchair. The resident, who was cognitively intact and dependent on staff for toileting and transfers, reported being unable to contact staff for help and experiencing anxiety about call light accessibility. Facility policy and the resident's care plan required the call light to be within reach, but this was not consistently ensured by staff.
A resident with dementia had a Quarterly MDS assessment completed, but the facility did not transmit the assessment data to the State within the required 14-day period. The delay was attributed to MDS staff being busy with end-of-month tasks, resulting in the assessment being sent more than three weeks after the assessment reference date.
A resident with an indwelling urinary catheter and a history of UTI and neurogenic bladder was observed on multiple occasions with catheter drainage bag and tubing in contact with the floor, contrary to the care plan and facility policy. The resident reported that the bag frequently drags on the floor and has become caught under the wheelchair wheel.
A resident who returned from the hospital with acute blood loss anemia was administered aspirin despite discharge instructions to discontinue the medication. The error occurred because previous medication orders were not discontinued in the electronic system, and the required admission checklist and order review process by two nurses was not properly followed.
Two residents experienced a lack of dignity and respect: one was subjected to a staff member's negative comment about their bowel care, and another reported feeling unimportant due to long delays in call light response and insufficient staffing, with staff often stating they were too busy or alone on the floor.
Two residents with dementia were involved in an incident where one was found touching the other inappropriately while the latter was not fully clothed. The staff member who witnessed the event informed an RN, but the required immediate reporting to the ED and state authorities did not occur. Key details were not communicated to management, and the incident was not reported to the state as required by policy.
Two residents with severe cognitive impairment were found in a private room, with one resident inappropriately touching the other, who was not fully clothed. The incident was witnessed by a CRCA, but the full details were not accurately reported to management or documented in the medical record. The facility failed to initiate a thorough investigation, did not interview the witness, and did not report the incident as required by policy.
Three residents did not receive care as ordered, including missed wound and skin treatments due to staff time constraints, and a resident experienced a repeat allergic reaction to Bactrim after the allergy was not timely documented or communicated, despite prior discussion with family and staff.
The facility failed to promote resident dignity by instructing a resident to use an incontinence brief instead of a bedpan and allowing a staff member to curse within hearing distance of another resident. The incidents involved a resident with severe cognitive impairment and behavioral issues, and another resident with a medical history of depression and an ostomy.
The facility failed to provide scheduled showers for two residents. One resident, with multiple diagnoses, did not receive showers twice a week as planned, and another mildly cognitively impaired resident only received four showers in two months. The facility's policy required bathing at least twice a week.
Failure to Transcribe Hospital Diabetes Orders Resulting in Missed Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and enter a hospital’s discharge orders for a newly admitted resident with type 2 diabetes into the facility’s electronic health record. The resident was admitted for a short-term rehab stay with diagnoses including type 2 diabetes, acute upper respiratory infection, unspecified dementia, weakness, dehydration, and hydrocephalus. The hospital discharge orders dated 2-6-26 specified that the resident had type 2 diabetes and was to receive glargine (Lantus) 16 units subcutaneously twice daily, with blood glucose (BG) monitoring before meals or three times daily. These diabetes-related orders, including the diagnosis and insulin regimen, were not transcribed into the facility’s electronic health record at admission and were not entered until 2-12-26. Multiple facility staff, including the Director of Health Services (DHS), MDS staff, a Nurse Practitioner, and two nurses, reviewed the hospital discharge paperwork and entered orders into the electronic health record but failed to identify and transcribe the diabetes diagnosis and associated insulin and BG monitoring orders. The DHS later explained that the initial page of the hospital discharge summary did not specifically mention the diabetes diagnosis, which was located further into the document, and that staff did not locate this information during the initial review. The omission was discovered on 2-11-26 during an initial care planning meeting when a family member inquired about the resident’s BG levels, prompting a more thorough review of the hospital discharge documents. During the period when the diabetes diagnosis and insulin orders were not in place, the resident did not receive the ordered long-acting insulin for five days and had only one insulin injection documented since admission. The resident’s BG levels during this time were significantly elevated, with readings including 399, 451, 496, 316, 360, 356, 422, and 354. The resident, who was already severely cognitively impaired per the 5-day MDS assessment, experienced diminished cognitive levels and lethargy and was ultimately sent to the local hospital at the family’s request. Hospital records from that subsequent admission documented altered mental status possibly related to dehydration, infection, or diabetic ketoacidosis, and identified the resident’s diabetes as uncontrolled at that time.
Removal Plan
- notification of the physician and the responsible party of the identified issues
- obtaining updated physician orders
- implementing the orders
- educating the licensed nursing staff on the facility's policies related to transcribing physician orders and diagnoses from the discharging entity into the facility's electronic health record
- initiated an audit system to ensure residents had accurately transcribed admission orders and diagnoses correctly documented into the facility's electronic health record system
Failure to Provide Sufficient Nursing Staff Resulting in Delayed and Missed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in delays in activities of daily living (ADL) care, skin care treatments, and incontinence care, as well as negatively impacting residents' dignity. Multiple residents and family members reported long wait times for assistance after pressing call lights, with some residents waiting up to 45 minutes for help with toileting, leading to incontinence accidents and emotional distress. Staff interviews confirmed that there were frequent staffing shortages, with only one Certified Resident Care Assistant (CRCA) often assigned to a hall, making it difficult to complete scheduled showers, skin care, and other essential care tasks in a timely manner. Staff members, including RNs, LPNs, and CRCAs, described an ongoing pattern of inadequate staffing, with frequent call-offs and management being unresponsive to urgent staffing needs. On one occasion, there was a documented 40-minute period when no nurse was present in the building, and staff had to rely on a nurse who had already worked a 16-hour shift and was attempting to leave. Staff reported being unable to complete required documentation, such as admission and skin assessments, and were sometimes instructed by management to backdate records to cover missed care. Resident Council meeting minutes over several months consistently reflected concerns about short staffing, delayed medications, and missed showers. The deficiency was further substantiated by time sheet reviews and interviews with the facility scheduler, who confirmed ongoing issues with filling shifts and the impact on resident care. The lack of adequate staffing led to missed or delayed care, falsification of shower records, and increased resident behaviors due to unmet needs. The survey cited related deficiencies in ADL care, quality of care, and resident dignity, with specific examples of residents not receiving timely shaving, skin care treatments, and respectful incontinence care.
Failure to Provide Timely ADL Assistance and Shaving for Dependent Residents
Penalty
Summary
The facility failed to provide timely and adequate assistance with activities of daily living (ADL) for several dependent residents, specifically in the areas of shaving and toileting. One resident, who preferred to maintain a goatee, was not assisted with shaving the rest of his face for over a week, despite his care plan specifying shaving on shower days and as needed. He reported that only one care assistant occasionally helped him, but often did not have time. Another resident, who required partial assistance with personal hygiene, was not shaved for over two weeks despite repeated requests, and only received assistance after persistent asking. His roommate confirmed that he had not been shaved since admission, despite being able to make his needs known and having a care plan that included shaving on shower days or as requested. Two other residents experienced significant delays in receiving toileting assistance, resulting in episodes of incontinence. One resident, who was usually continent but required substantial assistance due to mobility limitations, reported waiting up to 45 minutes for help after activating her call light, leading to incontinent accidents in bed. She described feeling anxious and embarrassed as a result. Another resident, also cognitively intact and dependent on staff for toileting, reported that her call light was not answered promptly, causing her to be incontinent and remain in a wet bed, which she found embarrassing and unnecessary. Staff interviews corroborated these findings, with a Certified Resident Care Assistant stating she was unable to complete bathing and ADL needs for residents on her assigned hall. The administrator confirmed that nursing staff were responsible for ensuring residents were shaved. The deficiencies were identified through observation, resident and staff interviews, and record review, and were associated with multiple complaints.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency was identified when a resident was repeatedly observed without access to their call light while seated in a wheelchair in the middle of their room. On two separate occasions, the call light was found on the floor or on the opposite side of the bed, out of the resident's reach. The resident reported being unable to contact staff for assistance during the day and expressed anxiety at night due to uncertainty about call light accessibility, sometimes having to yell for help. During one observation, the resident needed to use the restroom but could not summon assistance due to the inaccessible call light. The resident's clinical record indicated diagnoses of dementia, orthostatic hypotension, and muscle weakness, with a recent BIMS evaluation showing cognitive intactness. The MDS assessment documented the resident's dependence on staff for toileting and transfers, and the care plan included an intervention to keep the call light within reach due to fall risk. Facility policy also required staff to ensure call lights were accessible to residents. An RN confirmed that it was the responsibility of any staff member entering the room to ensure the call light was within reach.
Failure to Timely Transmit Quarterly MDS Assessment
Penalty
Summary
The facility failed to timely transmit a Quarterly Minimum Data Set (MDS) assessment for one resident diagnosed with dementia. The resident's clinical record showed that a Quarterly MDS assessment with an assessment reference date (ARD) was completed, but the transmission of this assessment to the State occurred significantly later than required. Specifically, the assessment was completed, but not transmitted within the 14-day window as outlined in the RAI Manual. According to MDS Support staff, the delay was due to being occupied with end-of-month activities, resulting in the assessment being transmitted more than three weeks after the ARD.
Failure to Maintain Catheter Bag and Tubing Off the Floor
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter drainage bag and tubing were kept off the floor, as required by facility policy and the resident's care plan. Resident E, who had diagnoses including urinary tract infection and neurogenic bladder, was observed on two separate occasions with his catheter drainage bag and tubing in contact with the floor while seated in his wheelchair. The resident reported that his catheter bag often drags on the floor and has previously become caught under his wheelchair wheel. The care plan specifically directed staff to ensure the catheter did not touch the floor, and the facility's urinary catheter care policy also required that catheter tubing and drainage bags be kept off the floor.
Failure to Discontinue Medication per Hospital Discharge Orders
Penalty
Summary
A deficiency occurred when the facility failed to follow hospital discharge orders for a resident who had recently returned from the hospital with a diagnosis of acute blood loss anemia. The hospital discharge summary specifically instructed discontinuation of aspirin 81 mg daily, but the Medication Administration Record showed that the resident received aspirin after readmission. The resident, who was cognitively intact, reported being told that all blood thinners would be held for a while following her hospitalization for blood loss. The Director of Health Services confirmed that the resident's previous medication orders were not discontinued in the computer system when she was transferred to the hospital, resulting in all prior orders reappearing on her MAR upon readmission. Although facility policy required an admission checklist and review of new or discontinued orders by two nurses, this process was not followed, leading to the administration of a medication that should have been discontinued. The resident's care plans identified risks related to bleeding and anemia, with interventions to administer medications as ordered, but these were not adhered to in this instance.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
The facility failed to promote and maintain resident dignity for two residents. For one resident with Parkinson's disease and bowel issues, a family member reported that a Certified Resident Care Assistant (CRCA) made a disrespectful comment about the resident's condition in his presence, describing the situation as 'gross.' The family filed a grievance, but the grievance log only documented concerns about missing supplies and dietary needs, not the staff's comment. Interviews with facility leadership revealed inconsistent recollections about the incident, with no documentation of the alleged disrespectful behavior, though a verbal warning was later issued to the CRCA for customer service concerns. The lack of clear documentation and follow-up on the dignity-related incident contributed to the deficiency. Another resident, who was cognitively intact and required significant assistance with activities of daily living, reported that insufficient staffing during night and early morning shifts led to long wait times for call lights to be answered, sometimes up to an hour. The resident expressed feeling unimportant and forgotten due to these delays and reported that staff often responded by saying they were too busy or the only CNA on the floor. This lack of timely assistance and communication failed to support the resident's dignity and emotional well-being.
Failure to Immediately Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving two residents with dementia, both of whom were assessed as severely cognitively impaired and unable to give consent. On the evening in question, a Certified Resident Care Assistant (CRCA) discovered one resident in another resident's room, with one resident touching the other's breast and thigh while the latter was not wearing pants. The CRCA separated the residents and informed the on-duty Registered Nurse (RN), but did not escalate the report to the Executive Director (ED) as required by facility policy, citing the ED's unavailability and a history of not answering calls. The RN, upon being informed, contacted the Assistant Director of Health Services (ADHS) but did not notify the ED or the Indiana Department of Health (IDOH). The ADHS, in turn, contacted corporate leadership but did not initiate a formal report to the state or conduct a thorough investigation, as she was not fully informed of the details of the incident, including the fact that one resident was not wearing pants and was being touched inappropriately. The Director of Health Services (DHS) and other members of the interdisciplinary team were also unaware of the full extent of the incident, as the CRCA was not interviewed and her account was not documented in detail. Facility policy required immediate reporting of suspected abuse to the ED and state authorities, but this process was not followed. The incident was not reported to the IDOH as a reportable event, and no internal investigation was initiated to gather statements or clarify the events from all involved staff. The lack of timely and complete reporting, as well as the failure to follow up with the primary witness, resulted in a deficiency related to the facility's abuse reporting procedures.
Failure to Investigate and Report Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to identify and initiate a thorough investigation into an alleged violation of abuse involving two residents with dementia. On the evening in question, a Certified Resident Care Assistant (CRCA) discovered one resident in another resident's room, with one resident touching the other's breast and thigh while the latter was not wearing pants. The CRCA separated the residents and reported the incident to the Registered Nurse (RN) on duty, who then notified the Assistant Director of Health Services (ADHS). However, the full details of the incident, including the inappropriate touching and the lack of clothing, were not accurately communicated up the chain of command. The RN and ADHS both failed to recognize the incident as potentially reportable abuse, relying on incomplete information and not conducting a thorough investigation. The Executive Director (ED) was not notified, and the CRCA was not interviewed or asked to provide a written statement about what she witnessed. The facility's documentation of the event was incomplete and did not reflect the severity of the situation, as the notes only mentioned hands on the leg and shoulder, omitting the more serious details reported by the CRCA. Both residents involved were documented as having severe cognitive impairment and lacking capacity to consent to intimate contact. Despite this, the facility did not initiate a formal investigation, did not report the incident as required, and did not follow its own abuse, neglect, and exploitation procedural guidelines. No reportable incident was filed with the state, and management staff were unaware of the full extent of the incident until interviewed during the survey.
Failure to Complete Treatments as Ordered and Timely Address Medication Allergy
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and failed to timely address a medication allergy for three residents. One resident with a history of urinary tract infections (UTIs) experienced a repeat allergic reaction to Bactrim, an antibiotic, after it was prescribed despite prior discussion of a possible allergy during a care plan meeting. The family reported swelling of the resident's lips after administration of Bactrim, with photographic evidence of similar reactions on two separate occasions. Documentation from the care plan meeting did not reference the allergy, and staff interviews revealed uncertainty and lack of documentation regarding the medication sensitivity discussed. The allergy was only formally documented in the resident's record after the most recent reaction occurred. Another resident with diabetes and skin impairments had a physician's order for foam dressing changes on specific days. The treatment was not completed on one occasion, with the reason documented as "not enough time." The nurse responsible indicated that due to time constraints during her shift, she was unable to complete all assigned treatments, including the required dressing change for this resident. The resident was cognitively intact at the time of the deficiency. A third resident with acute respiratory failure and chronic pulmonary edema had a physician's order for Profore two-step dressing changes to the lower extremities on scheduled days. The dressing change was not completed as ordered, with documentation indicating insufficient time or staff as the reason. Interviews with nursing staff confirmed that wound care tasks were delayed or missed due to workload, and the resident reported that his leg dressings were changed later than scheduled. Facility policy required adherence to physician recommendations for treatment, which was not followed in these instances.
Failure to Promote Resident Dignity
Penalty
Summary
The facility failed to promote a resident's dignity by instructing Resident H to use an incontinence brief instead of a bedpan and by allowing a staff member to curse within hearing distance of Resident F. Resident F, who had severe cognitive impairment and various behavioral symptoms, was involved in an incident where a staff member was heard cursing while providing care. The staff member, CRCA 3, was reportedly frustrated after being pushed by Resident F and falling onto an activity table, which broke. Although the cursing was not directed at Resident F, it was within his hearing range, and the incident was reported by the payroll coordinator and investigated by the facility. The investigation concluded with no findings of verbal abuse, and the staff member was allowed to return to work. However, the incident still raised concerns about maintaining a dignified environment for residents, especially those with cognitive impairments and behavioral issues. Resident H, who had a medical history of depression and an ostomy due to complications from a previous procedure, was also affected by the facility's failure to promote dignity. Resident H was continent of her bladder and used a bedpan for toileting due to being non-weight-bearing after a recent foot procedure. On the morning of 4/25/2024, Resident H requested a bedpan, but the night shift nurse instructed her to use her brief instead, stating that she would have to change her anyway. This interaction made Resident H feel upset, frustrated, and disrespected. The nurse eventually provided the bedpan after a brief argument, but the incident highlighted a lack of respect for Resident H's dignity and personal preferences. The facility's policy on Resident Rights Guidelines emphasizes treating residents with dignity, respect, and courtesy. However, the incidents involving Resident F and Resident H demonstrate a failure to adhere to these guidelines. The report indicates that the facility did not adequately promote a dignified existence for these residents, leading to feelings of frustration and disrespect. The deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers as scheduled for two residents, Resident K and Resident B. Resident K reported not receiving her showers twice a week as scheduled, with staff offering showers at inconvenient times. Her record indicated she was admitted with multiple diagnoses, including metabolic encephalopathy, severe sepsis, and acute respiratory failure, and required substantial assistance for bathing. The care plan specified she should receive showers on Wednesdays and Saturdays after 6 p.m., but documentation showed she only received eight showers from March 1 to April 17, instead of the expected nine in March alone. Resident B, who was mildly cognitively impaired and dependent on staff for bathing, also did not receive showers as scheduled. His care plan indicated he should receive showers on Mondays and Thursdays. However, documentation revealed that in the two months he was at the facility, he only received four showers. The facility's policy stated that bathing should occur at least twice a week unless otherwise preferred by the resident. This deficiency was related to a complaint investigation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greenfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Greenfield | 0.6 mi | ★★★★★ | 25 | 0 |
| Greenfield Healthcare Center | 1.7 mi | ★★★★★ | 11 | 0 |
| Brickyard Healthcare - Brandywine Care Center | 2 mi | ★★★★★ | 11 | 0 |
| Majestic Care Of Mccordsville | 8.7 mi | ★★★★★ | 0 | 0 |
| Morristown Manor | 10.4 mi | ★★★★★ | 0 | 0 |
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