Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Mill Meadows during CMS and state inspections, most recent first.
A staff member failed to use a gait belt during a transfer of a resident identified as a high fall risk, resulting in the resident falling and sustaining a head abrasion and a right femur fracture. The resident required substantial assistance for transfers, and facility policy mandated gait belt use for such situations. The CNA did not follow this policy, leading to the incident and injury.
A facility failed to provide a resident with prescribed cancer medication and did not schedule necessary follow-up oncology appointments. The resident, with metastatic prostate cancer, was admitted to the facility and was supposed to continue receiving Nubeqa. However, the medication was not provided due to a lack of a prescription script, and the medical director discontinued it citing high cost without consulting the oncologist. No follow-up oncology care was scheduled for 15 months, resulting in inadequate cancer management.
The facility failed to notify physicians and adhere to medication orders for five residents, leading to deficiencies in care. Residents experienced issues such as unreported high blood sugar levels, administration of medications outside hold parameters, and missed medication doses. The DON confirmed the lack of documentation and policies for physician notification, contributing to these deficiencies.
A resident with multiple health issues was improperly transferred by staff, contrary to physical therapy recommendations, leading to an incident where the resident's legs gave out. The care plan specified the use of a mechanical lift, but the order was not properly documented, resulting in staff using an unsafe transfer method.
A facility failed to conduct a timely AIMS assessment for a resident on Risperidone, an antipsychotic, and did not educate on associated black box warnings. The resident, with multiple diagnoses including dementia, was prescribed Risperidone, but the first AIMS assessment was delayed by over a month. Additionally, no education was provided on the increased risks of death and cerebrovascular events in dementia patients taking antipsychotics.
The facility failed to ensure proper medication storage and labeling, with loose medications found in carts, unlabeled dosages, and discrepancies in narcotic counts. Staff interviews revealed a lack of adherence to procedures for medication destruction and reconciliation.
A resident with multiple health conditions was not assisted in obtaining dentures despite a dental recommendation made months earlier. Observations showed the resident eating soft foods due to being edentulous. Interviews revealed no action had been taken to follow up on the dental recommendation, contrary to the facility's policy on dental services.
The facility failed to maintain proper food storage practices in the walk-in freezer, with several items found in unsealed and wet or ice-covered boxes. The Dietary Manager and Maintenance Supervisor acknowledged issues with condensation and improper defrosting methods. A resident reported that the chicken tasted as if it had been refrozen, indicating potential mishandling. The facility's policy requires frozen foods to remain solid and tightly wrapped, which was not followed.
A resident with severe cognitive impairment was incorrectly transferred to her previous home address instead of an assisted living facility due to a human error in providing the wrong address to the transport company. The resident was left in a driveway, and her son had to retrieve her after being notified by a neighbor. The facility confirmed the mistake was due to using the wrong address from the resident's face sheet.
Failure to Use Gait Belt During Transfer Results in Resident Fall and Injury
Penalty
Summary
A staff member failed to follow facility policy and procedure regarding the use of a gait belt during a resident transfer, resulting in a fall. The incident involved a resident who was identified as a high fall risk, with diagnoses including muscle weakness, chronic respiratory failure, and chronic kidney disease with heart failure. The resident required substantial to maximal assistance for transfers and was cognitively intact. During the transfer from bed to wheelchair, the CNA did not use a gait belt as required by facility policy and instead held the resident by her pants, leading to the resident falling backward and sustaining injuries. The resident's family member witnessed the aftermath of the fall, finding the resident on the floor with blood coming from her head. The clinical record and hospital documentation confirmed that the resident suffered an abrasion to the forehead and a nondisplaced intertrochanteric fracture of the right femur, which required emergency surgery. The CNA involved acknowledged not using a gait belt and reported that care sheets were unavailable at the time of the incident. Multiple staff interviews confirmed that the use of gait belts was standard practice for all transfers unless a mechanical lift was used. Facility documentation showed that the CNA had completed training on gait belt use and that the facility's policies clearly required gait belts for all non-independent transfers. The failure to use a gait belt during the transfer directly led to the resident's fall and subsequent injury.
Failure to Provide Cancer Treatment and Follow-Up Care
Penalty
Summary
The facility failed to ensure that a resident received the prescribed medication for cancer treatment and did not schedule follow-up appointments with an oncologist. The resident, who had metastatic prostate cancer, was admitted to the facility in October 2023. Upon admission, the resident was supposed to continue receiving Nubeqa, a hormone therapy medication, as part of his cancer treatment. However, the medication was not provided due to a lack of a prescription script, and the facility's medical director later discontinued the medication citing its high cost, without consulting the resident's oncologist. The resident's clinical records indicated that there was no follow-up oncology care scheduled until January 2025, which was 15 months after the resident's admission to the facility. During this period, the resident did not receive the necessary cancer treatment, and there was no documentation of any consultation with the oncologist. The facility's Director of Nursing was unaware of the oncology referral appointment that was supposed to be scheduled following the resident's discharge from the hospital. The deficiency resulted in the resident not receiving appropriate cancer treatment and follow-up care, which was crucial for managing his metastatic prostate cancer. The facility's policy required verification of physician orders and pharmacy notification upon admission, but these procedures were not adequately followed. The medical director responsible for discontinuing the medication was no longer employed at the facility, and the facility was unable to obtain further information regarding the decision to discontinue the cancer medication.
Failure to Adhere to Physician Orders and Notify Physicians
Penalty
Summary
The facility failed to ensure proper notification and adherence to physician's orders for five residents, leading to deficiencies in quality of care. Resident J, diagnosed with type 2 diabetes mellitus, chronic kidney disease, and dementia, had blood sugar levels recorded above the physician-ordered parameters on multiple occasions without documentation of physician notification. The Director of Nursing (DON) confirmed the lack of documentation for notifying the physician when blood sugar levels were outside the ordered parameters. Resident H, with chronic systolic congestive heart failure, received Hydralazine despite systolic blood pressure readings below the ordered hold parameter. The Medication Administration Record (MAR) showed that the medication was administered on several occasions when it should have been held. Similarly, Resident K, with acute systolic heart failure and other conditions, was given Metoprolol and Furosemide when systolic blood pressure readings were below the hold parameters. The DON acknowledged the administration of medications outside the ordered parameters and noted the absence of a policy on holding medications. Resident B reported missing several medication doses, which was confirmed by the MAR. The missed medications included inhalers, antibiotics, and mouthwash, with no documentation of physician notification. Resident 37, with a history of hypertension and heart failure, had systolic blood pressure readings above the physician-ordered notification parameters without evidence of physician notification. The DON indicated that these readings were considered normal for the resident and were placed on a non-urgent list for the physician. The facility lacked a policy for physician notification, contributing to these deficiencies.
Failure to Follow PT Transfer Recommendations
Penalty
Summary
The facility failed to ensure that the physical therapy recommended method for transferring a resident was followed, leading to an incident involving Resident E. The resident, who had diagnoses including morbid obesity, anemia, weakness, and was receiving surgical aftercare, was being transferred by two staff members from her bed to her wheelchair when her legs gave out, and she was lowered to the floor. The physical therapy evaluation had recommended the use of a Hoyer or sit-to-stand lift for transfers due to medical reasons and safety concerns, but this recommendation was not followed during the transfer. The care plan for Resident E indicated the need for assistance with activities of daily living, including transfers, and specified the use of a sit-to-stand lift. However, there was no physician's order for a Hoyer lift or sit-to-stand lift found in the clinical record. The Director of Therapy noted that the nursing staff had failed to keep the order for the use of a Hoyer lift open-ended, leading to its immediate discontinuation. Additionally, the sit-to-stand lift was added to the care plan by word of mouth rather than through proper documentation, resulting in the staff attempting an under-the-arm transfer, contrary to the physical therapy recommendations.
Failure to Conduct Timely AIMS Assessment and Educate on Antipsychotic Risks
Penalty
Summary
The facility failed to conduct an Abnormal Involuntary Movement Scale (AIMS) assessment on a resident who was prescribed an antipsychotic medication, Risperidone, for over a month. The resident, who had diagnoses including generalized anxiety disorder, major depressive disorder, dementia, unspecified psychosis, altered mental status, and insomnia, was started on Risperidone with physician's orders dated 7/5/24. The care plan indicated that an AIMS assessment should be completed twice a year, but the first assessment was not conducted until 8/27/24, more than a month after the medication was initiated. This delay in assessment was confirmed by the Director of Nursing (DON) during an interview. Additionally, the facility did not provide education on the black box warnings associated with the use of antipsychotic medications in patients with dementia. Interviews with the DON and the Executive Director (ED) revealed that there was no education provided regarding the increased risk of death and cerebrovascular events in dementia patients taking antipsychotics, as highlighted by a study from the National Institute of Health (NIH). The facility's policy on psychotropic management, which was last reviewed in October 2022, required an AIMS assessment within 72 hours of initiating or increasing antipsychotic medication, but this was not adhered to in the case of the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices across three medication carts. During observations, loose medications were found in the drawers of medication carts 1 and 3, including various pills and capsules. Additionally, a card of Tramadol for a resident was found with white tape holding a tablet in place, indicating improper handling. Medication cart 4 contained dosages of hydralazine and sodium chloride without pharmacy labels, and an inhaler with a handwritten name instead of a proper label. These findings suggest a lack of adherence to labeling and storage protocols. Furthermore, discrepancies were noted in the narcotic count logs. For instance, a narcotic reconciliation on medication cart 3 revealed an inconsistency in the Tramadol count for a resident, where the log indicated one less tablet than was present. This discrepancy was acknowledged by an LPN, who admitted the dose was not given despite being signed out. Interviews with staff, including LPNs and the Director of Nursing, highlighted a lack of clarity and adherence to the facility's procedures for medication destruction and reconciliation, contributing to the deficiencies observed.
Failure to Assist Resident in Obtaining Dentures
Penalty
Summary
The facility failed to assist a resident, identified as Resident 20, in obtaining dentures as recommended during a dental examination. Observations on two separate occasions revealed that the resident was eating soft foods and was edentulous, indicating the absence of teeth. The resident's clinical record showed multiple diagnoses, including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, bipolar disorder, schizophrenia, dementia with agitation, dysphagia oral phase, and mild intellectual disabilities. A dental examination conducted in February recommended that the resident, who expressed a desire for dentures, was a good candidate for complete upper and lower dentures, and impressions should be obtained. Despite this recommendation, a social services note from February indicated no new recommendations were made, and a care plan revised in June still noted the resident's edentulous status without dentures. Interviews with the resident and the Social Services Assistant in August confirmed that no further action had been taken to obtain dentures since the initial recommendation. The facility's policy on dental services, which mandates obtaining needed dental services and making prompt referrals, was not adhered to in this case, leading to the deficiency.
Improper Food Storage Practices in Walk-in Freezer
Penalty
Summary
The facility failed to ensure proper food safety practices in the walk-in freezer, as observed during a kitchen inspection. Several food items, including garlic toast, pork sausage links, egg omelets, egg rolls, cheese omelets, marinated diced white chicken, and diced ham, were found stored in unsealed bags and boxes that were either wet or covered in ice. The Dietary Manager acknowledged the presence of ice-covered and wet boxes, attributing it to condensation as explained by the food service delivery person. Additionally, a resident reported that the chicken tasted as if it had been frozen, thawed, and then refrozen, indicating potential mishandling of food storage. The Maintenance Supervisor admitted that moisture and condensation occurred during the stocking of supplies and described his method of defrosting the freezer, which involved shutting off the power and leaving the door open without taking measures to catch melting ice. The Administrator noted that the freezer was supposed to be auto-defrosting and should not require manual defrosting. The facility's current food storage policy, last revised in May 2024, mandates that frozen foods should remain solid, be tightly covered or wrapped, and not be refrozen after thawing, which was not adhered to in this instance.
Resident Transfer Error Due to Incorrect Address
Penalty
Summary
The facility failed to ensure a proper transfer for a resident, identified as Resident F, due to an incorrect address being provided to the transport company. Resident F, who had severe cognitive impairment and multiple medical diagnoses including malignant neoplasm of the lung and dementia, was supposed to be transferred to an assisted living facility. However, the transport company mistakenly took her to her previous home address and left her in the driveway, as the wrong address was given by the facility's Social Services Director. The incident was discovered when Resident F's son and a neighbor called the facility to report that the resident had been left at the wrong location. The neighbor attempted to alert the transport driver, but the driver left without addressing the situation. The resident's son had to leave work to pick her up, finding her in soiled clothes, which he had to change before taking her to the correct assisted living facility. Interviews with facility staff, including the Executive Director and Social Services Assistant, confirmed that a human error led to the wrong address being provided to the transport company. The facility had a contract with the transport company for resident transportation, but the address on the resident's face sheet was mistakenly used instead of the assisted living facility's address. This error was not the first instance of incorrect addresses being given to the transport company.
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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 Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Willow Springs Care Center | 0.1 mi | — | 0 | 0 |
| St Augustine Home For The Aged | 0.2 mi | — | 0 | 0 |
| Marquette | 0.5 mi | — | 3 | 0 |
| Harcourt Terrace Nursing And Rehabilitation | 0.6 mi | — | 25 | 0 |
| Hooverwood | 2.4 mi | — | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.