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Complaint Investigation

Willows Of Richmond

Inspection Date: October 15, 2025
Total Violations 1
Facility ID 155228
Location RICHMOND, IN
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Inspection Findings

F-Tag F0585

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on interview and record review, the facility failed to assure a grievance was forwarded to the grievance official for a lost item for 1 of 4 residents reviewed for grievances.(Resident B) Findings include:The clinical record for Resident B was reviewed on 10/14/25 at 1:30 p.m. The diagnoses included, but were not limited to, hypertension and flaccid hemiplegia ( a condition where one side of the body experiences weakness and loss of muscle tone).The Annual Minimum Data Set (MDS) assessment, dated 9/5/25, indicated Resident B was cognitively intact.During an interview with Resident B, on 10/14/25 at 2:05 p.m., the resident indicated they had lost their cell phone a couple of months ago. The resident had told nursing staff about the lost phone, but no one had ever followed up with her about it. Resident B indicated

she would have to go to the nurse's station to make or receive any phone calls.During an interview with Certified Nursing Assistant (CNA) 2 on 10/14/25 at 2:18 p.m. CNA 2 indicated Resident B did have a cell phone (flip phone) that she would use and a couple of months ago, The resident had indicated they did not know where their cell phone was at. CNA 2 indicated she had not filed a grievance form for Resident B, but

she told the Social Service Director (SSD) about the missing cell phone.During an interview with the SSD

on 10/14/25 at 2:25 p.m., they indicated they could not remember if CNA 2 had told them about Resident B having a missing phone. The SSD indicated a grievance form was never filled out for Resident B's missing cell phone. The person receiving the grievance was who needed to fill out a grievance form and then it would be given to herself or placed under her door (if she was gone) to follow up on.The plan of care for Resident B, dated 11/14/24, indicated Resident B enjoyed activities such as talking with her family on the phone.The Resident and Family Grievances policy was provided by the Director of Nursing (DON) on 10/15/25 at 12:46 p.m. It indicated,.1. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility.6. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member.8. Procedure: b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form.c. Forward the grievance form to the Grievance Official as soon as practicable.e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. This citation relates to intake 26398823.1-7(a)(2)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

WILLOWS OF RICHMOND in RICHMOND, IN inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in RICHMOND, IN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WILLOWS OF RICHMOND or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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