Inspection Reports for Grand Brook Memory Care of Fishers
9796 E 131st St, Fishers, IN 46038, United States, IN, 46038
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Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Jul 7, 2025
Visit Reason
This visit was conducted for the investigation of complaint IN00462471 regarding the use of a physical restraint by a third party caregiver on a resident.
Findings
The facility failed to implement their policy for protecting resident rights by not reporting the use of a physical restraint applied by a third party caregiver on Resident C. The gait belt was used as a restraint without proper authorization, and the third party caregiver was removed from the facility. Resident C experienced no long-term adverse effects.
Complaint Details
Complaint IN00462471 was substantiated with state deficiencies cited related to the allegations of improper use of physical restraint by a third party caregiver on Resident C.
Deficiencies (1)
| Description |
|---|
| Failure to report to the Administrator or designee the observed use of a physical restraint applied by a third party caregiver for Resident C. |
Report Facts
Residential Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Drey | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
| RN 3 | Observed restraint use, failed to notify DON, received re-education on resident rights and facility policies | |
| Third Party CNA 4 | Applied unauthorized physical restraint to Resident C and was removed from the facility | |
| DON | Director of Nursing | Discovered restraint use, removed restraint, and instructed Third Party CNA 4 to leave |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Apr 16, 2025
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00455933.
Findings
No deficiencies related to the complaint allegations were cited. However, a deficiency was found related to a Certified Nursing Assistant (CNA 3) who did not have a valid Indiana Nurse Aide certification, potentially impacting all 34 residents.
Complaint Details
Complaint IN00455933 was investigated and no deficiencies related to the allegations were cited.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a Certified Nursing Assistant (CNA 3) had a valid Indiana Nurse Aide certification. |
Report Facts
Residential Census: 34
Shifts worked: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Drey | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Mar 18, 2025
Visit Reason
This visit was conducted to investigate Complaints IN00453552 and IN00454500 at Grand Brook Memory Care of Fishers.
Findings
No deficiencies related to the allegations in Complaints IN00453552 and IN00454500 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Investigation of Complaints IN00453552 and IN00454500 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Residential Census: 36
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Feb 12, 2025
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00449580, IN00451151, IN00451929, IN00452137, IN00452217, IN00452346, and IN00452415) at Grand Brook Memory Care of Fishers.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with applicable regulations regarding the investigation of these complaints.
Complaint Details
Seven complaints were investigated: IN00449580, IN00451151, IN00451929, IN00452137, IN00452217, IN00452346, and IN00452415. None of these complaints resulted in any cited deficiencies.
Report Facts
Complaint investigations: 7
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Oct 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440869.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations regarding the complaint investigation.
Complaint Details
Complaint IN00440869 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Jul 16, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00434534, IN00430196, and IN00426917.
Findings
No deficiencies related to the complaints were cited. However, the facility failed to ensure the most recent survey results were readily available for residents and resident representatives, as the survey binder was kept in a locked staff workroom requiring staff assistance to access.
Complaint Details
Complaints IN00434534, IN00430196, and IN00426917 were investigated with no deficiencies related to the allegations cited.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the most recent survey results were readily available for residents and resident representatives. |
Report Facts
Residential Census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Present in the locked workroom and located the survey binder | |
| Community Relations Director | Indicated previous survey binder results used to be in the lobby but had gone missing several times | |
| Administrator | Explained the survey binder was moved to a locked staff office due to residents moving or taking the binder |
Inspection Report
Follow-Up
Census: 35
Deficiencies: 0
Sep 27, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00412712 completed on 2023-08-01.
Findings
Grand Brook Memory Care of Fishers was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00412712.
Complaint Details
Complaint IN00412712 was corrected as of the survey date 2023-09-27.
Report Facts
Residential Census: 35
Inspection Report
Renewal
Census: 36
Deficiencies: 2
Aug 15, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 15 and 16, 2023.
Findings
The facility was found deficient in sanitation and safety standards related to laundry room cleanliness and safety, and in medication administration documentation where QMAs failed to obtain and document authorization from a licensed nurse for PRN medications.
Deficiencies (2)
| Description |
|---|
| Failed to ensure a clean, safe environment in 2 of 2 laundry units observed, including lint and dust accumulation and disconnected dryer vent hose. |
| Failed to obtain and document authorization from a licensed nurse when QMAs administered PRN medications for one resident and others. |
Report Facts
Residential Census: 36
Deficiency count: 2
Residents reviewed for medication administration: 7
Additional residents lacking proper PRN documentation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Drey | Executive Director | Signed the report |
| Director of Nursing | Reviewed PRN administration, documented observations, and involved in corrective actions |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Aug 1, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00412712 regarding state deficiencies related to allegations of unsafe storage of hand sanitizer and hazardous chemicals accessible to ambulatory residents.
Findings
The facility failed to ensure secure storage of hand sanitizer for a cognitively impaired resident who drank from the container and failed to ensure proper storage of hazardous chemicals accessible to 23 ambulatory residents. Immediate corrective actions included removal of chemicals and sanitizers from accessible areas and staff in-service training on chemical storage.
Complaint Details
Complaint IN00412712 was substantiated with state deficiencies cited at R0148 related to unsafe chemical and hand sanitizer storage accessible to residents, including an incident where Resident 3 was observed attempting to drink hand sanitizer.
Deficiencies (1)
| Description |
|---|
| Failure to ensure secure storage of hand sanitizer for a cognitively impaired resident who drank from the container and failure to ensure proper storage of hazardous chemicals accessible to ambulatory residents. |
Report Facts
Residential Census: 36
Ambulatory Residents: 23
Deficiency Completion Date: Sep 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Drey | Executive Director | Signed the report |
| LPN 3 | Interviewed and provided information about wandering residents and the hand sanitizer incident | |
| QMA 4 | Interviewed and informed about the hand sanitizer incident | |
| HHA 5 | Provided eyewitness account of Resident 3 drinking hand sanitizer | |
| Administrator | Provided incident report, in-service log, and facility policy; interviewed regarding chemical storage | |
| DON | Director of Nursing | Conducted facility tour and interviews; acknowledged improper chemical storage |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Jul 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408582.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations regarding the complaint.
Complaint Details
Complaint IN00408582 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 36
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Apr 18, 2023
Visit Reason
This visit was for the investigation of Complaint IN00403603.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00403603 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Feb 2, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00397811.
Findings
Complaint IN00397811 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00397811 - Substantiated. No deficiencies related to the allegations are cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 9, 2023
Visit Reason
Paper compliance review to the State Residential Licensure Survey completed on November 15, 2022.
Findings
Grand Brook Memory Care of Fishers 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 State Residential Licensure Survey.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Dec 26, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00397691.
Findings
Complaint IN00397691 was substantiated, but no State Residential Findings related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00397691 - Substantiated. No State Residential Findings related to the allegations were cited.
Report Facts
Residential Census: 35
Inspection Report
Renewal
Census: 33
Deficiencies: 4
Nov 15, 2022
Visit Reason
This visit was for a State Residential Licensure Survey conducted on November 14 and 15, 2022, to assess compliance with state residential care regulations.
Findings
The facility was found noncompliant in several areas including failure to conduct required quarterly fire drills on each shift for 8 of 12 months reviewed, failure to obtain references for new employees in 5 of 5 employee files reviewed, failure to provide general and job-specific orientation for new employees, and failure to provide required dementia training for staff working in a dementia care facility.
Deficiencies (4)
| Description |
|---|
| Failure to ensure fire drills were conducted quarterly on each shift for 8 of 12 months reviewed. |
| Failure to obtain references for new employees for 5 of 5 employee files reviewed. |
| Failure to provide general and job-specific orientation to employees hired to work at the facility for 5 of 5 employee files reviewed. |
| Failure to provide education regarding the care of residents with dementia for staff working in a dementia care facility for 3 of 5 employee files reviewed. |
Report Facts
Residential Census: 33
Months lacking fire drills: 8
Employees missing references: 5
Employees missing orientation: 5
Employees missing dementia training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Drey | Executive Director | Named as the Administrator who acknowledged deficiencies and described corrective actions. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Aug 26, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00382440.
Findings
The complaint IN00382440 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00382440 was investigated and found unsubstantiated due to lack of evidence.
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