Inspection Reports for Grand Brook Memory Care of Greenwood

2444 S State Rd 135, Greenwood, IN 46143, United States, IN, 46143

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Inspection Report Summary

The most recent inspection on December 27, 2024, found the facility to be in compliance with state residential licensure requirements and cited no deficiencies. Earlier inspections showed a mix of compliance and deficiencies, including issues with fire drills, first aid staffing, securing mechanical rooms, resident documentation, posting of residents’ rights and contact information, resident transfer practices, and hand hygiene. Complaint investigations were mostly unsubstantiated, though one complaint was substantiated without related deficiencies cited. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The inspection history suggests improvement over time, with the most recent survey showing no deficiencies after prior citations.

Deficiencies (last 3 years)

Deficiencies (over 3 years) 3.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

21% better than Indiana average
Indiana average: 4.2 deficiencies/year

Deficiencies per year

8 6 4 2 0
2022
2023
2024

Census

Latest occupancy rate 22 residents

Based on a December 2024 inspection.

This facility has shown a decline in demand based on occupancy rates.

Census over time

14 21 28 35 42 Sep 2022 Mar 2023 Dec 2023 Sep 2024 Dec 2024
Inspection Report Renewal Census: 22 Deficiencies: 0 Dec 27, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on December 26 and 27, 2024.
Findings
Grand Brook Memory Care of Greenwood was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
Inspection Report Complaint Investigation Census: 25 Deficiencies: 0 Sep 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443451.
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 IN00443451 was investigated and found to have no deficiencies related to the allegations.
Inspection Report Renewal Census: 23 Deficiencies: 5 Jan 23, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on January 22 and 23, 2024, to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in several areas including failure to conduct monthly fire drills for 7 of 12 months, lack of 24-hour first aid certified staff for 7 of 7 days reviewed, unsecured mechanical rooms posing safety hazards, failure to document resident weights upon admission for 4 of 7 residents reviewed, and incomplete tuberculin skin testing for 1 of 7 residents reviewed.
Deficiencies (5)
Description
Failed to ensure fire drills were held monthly for 7 of 12 months reviewed.
Failed to ensure a First Aid certified staff member was on site 24 hours a day for 7 of 7 days reviewed.
Failed to ensure mechanical rooms were secured for 3 of 3 observations, exposing residents to hazards.
Failed to ensure a resident's weight was taken or documented upon admission for 4 of 7 residents reviewed.
Failed to ensure a first step tuberculin skin test was completed prior to or upon admission or a second step tuberculin skin test was completed within one to three weeks after the first step for 1 of 7 residents reviewed.
Report Facts
Residential Census: 23 Months without fire drills: 7 Days without First Aid certified staff: 7 Residents missing admission weight: 4 Residents missing proper tuberculin skin test: 1
Employees Mentioned
NameTitleContext
Milissa DownsExecutive DirectorProvided fire drill reports, facility policies, and interviews related to deficiencies
Director of Health ServicesProvided facility fire procedure, clinical record reviews, and interviews related to deficiencies
Inspection Report Complaint Investigation Census: 23 Deficiencies: 0 Dec 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423834.
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 IN00423834 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 23
Inspection Report Complaint Investigation Census: 21 Deficiencies: 0 Nov 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420012.
Findings
No deficiencies related to the allegations in Complaint IN00420012 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00420012 was investigated and found to have no deficiencies related to the allegations.
Inspection Report Complaint Investigation Census: 36 Deficiencies: 5 Mar 1, 2023
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00402041.
Findings
The complaint was substantiated but no deficiencies related to the allegations were cited. The facility was found deficient in posting residents' rights and organizational contact information in publicly accessible areas, providing access to the most recent annual state survey, ensuring proper resident transfer using gait belts, and enforcing hand hygiene and glove changes during resident care.
Complaint Details
Complaint IN00402041 was substantiated but no deficiencies related to the allegations were cited.
Deficiencies (5)
Description
Failed to ensure a copy of the residents' rights was available in a publicly accessible area for 2 of 3 days during the survey.
Failed to ensure the known addresses and telephone numbers of state and local agencies were posted in an area accessible to residents for 2 of 3 days during the survey.
Failed to provide residents with a readily accessible location of the most recent annual state survey for 2 of 3 days during the survey.
Failed to ensure a resident was transferred using a gait belt per facility policy for 1 of 3 residents reviewed for wound care.
Failed to ensure staff performed hand hygiene and changed gloves after performing perineal care for 1 of 3 residents observed for wound care.
Report Facts
Survey dates: February 27, 28, and March 1, 2023 Residents present: 36 Completion date for systemic changes: 03/29/2023 for all corrective actions
Employees Mentioned
NameTitleContext
Brittany McKinneyHFALaboratory Director's or Provider/Supplier Representative's signature on report
Caregiver 1Observed transferring Resident 2 without gait belt and performing perineal care without proper hand hygiene
Caregiver 2Observed performing perineal care without proper hand hygiene
Caregiver 3Observed transferring Resident 2 without gait belt and interviewed about gait belt availability
Director of Quality & TrainingCorporate Director of Quality and TrainingProvided facility policies and interviews regarding postings and survey book accessibility
Assistant Director of NursingProvided facility policy on transfers
Director of NursingDONIndicated proper hand hygiene and glove change were required during perineal care
Director of Community RelationsProvided infection control policy
Inspection Report Complaint Investigation Census: 30 Deficiencies: 0 Jan 4, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00392764, IN00396022, and IN00398189.
Findings
Complaint IN00392764 was unsubstantiated due to lack of evidence. Complaint IN00396022 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00398189 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations regarding these complaints.
Complaint Details
Complaint IN00392764 - Unsubstantiated due to lack of evidence. Complaint IN00396022 - Substantiated. No deficiencies related to the allegations are cited. Complaint IN00398189 - Unsubstantiated due to lack of evidence.
Report Facts
Complaint investigations: 3
Inspection Report Complaint Investigation Census: 36 Deficiencies: 0 Sep 21, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00385858.
Findings
Complaint IN00385858 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 investigation.
Complaint Details
Complaint IN00385858 was unsubstantiated due to lack of evidence.

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