Inspection Reports for Grand Brook Memory Care of Zionsville
11870 Sandy Dr, Zionsville, IN 46077, United States, IN, 46077
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 7, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed pattern, with prior reports citing deficiencies in infection control, medication labeling, food safety, employee training, and discharge procedures. Inspectors noted issues such as failure to report a COVID-19 outbreak, inadequate infection control practices, incomplete employee reference checks, and improper involuntary discharge processes. Complaint investigations were mostly unsubstantiated except for one substantiated case involving an improper involuntary discharge that caused psychosocial harm to a resident. The facility’s recent inspections suggest some improvement, particularly with no deficiencies found in the latest complaint investigations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
35 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Apr 7, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456668.
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 IN00456668 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Dec 30, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00441934.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00441934.
Complaint Details
Complaint IN00441934 - No deficiencies related to the allegations are cited.
Inspection Report
Renewal
Census: 36
Deficiencies: 5
Jun 24, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on June 21 and 24, 2024, to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in several areas including failure to report a new COVID-19 outbreak, inadequate food labeling and sanitation practices in the kitchen, improper medication labeling, failure to maintain infection control practices during medication administration, and lack of an effective infection control system to track infections and outbreaks.
Deficiencies (5)
| Description |
|---|
| Failed to report a new outbreak of COVID-19 to the Indiana Department of Health for 3 residents. |
| Failed to ensure all foods were labeled and dated with open and expiration dates, large trash cans were covered, hand hygiene was properly completed, lunch foods maintained at safe temperatures, and thermometer sanitized between uses. |
| Failed to date medications when opened and label over-the-counter medications properly in medication rooms. |
| Failed to maintain infection control practices while passing sublingual medication for one resident, including reuse of oral syringes without proper disinfection. |
| Failed to implement an infection control system to analyze new and ongoing infections and identify trends for 4 of 6 months reviewed, including lack of documentation of COVID-19 outbreak and urinary tract infection cultures. |
Report Facts
Residential Census: 36
Survey Dates: 2
COVID-19 Positive Residents: 3
Vaccination Counts: 4
Vaccination Counts: 2
Vaccination Counts: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherri Dawson | Executive Director | Named as Executive Director and involved in reporting and policy oversight |
| LPN 13 | Observed failing to maintain infection control practices during medication pass | |
| Chef 9 | Observed food handling deficiencies in kitchen | |
| Director of Health Services | Provided infection control program information and policies | |
| Director of Nursing | Provided medication storage policy and oversight | |
| Maintenance Director | Provided information on kitchen tours and food labeling |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 5
Sep 7, 2023
Visit Reason
This visit was for a State Residential Licensure Survey, which included the investigation of Complaint IN00414443.
Findings
No deficiencies related to the complaint allegations were cited. However, multiple deficiencies were found including failure to complete reference checks for a new employee, insufficient CPR and first aid coverage on shifts, lack of annual in-service training for some employees, failure to obtain required chest x-rays for residents, and failure to ensure tuberculosis skin testing was conducted as required.
Complaint Details
Complaint IN00414443 was investigated and no deficiencies related to the allegations were cited.
Deficiencies (5)
| Description |
|---|
| Failed to ensure reference checks were completed for a new employee before they started working. |
| Failed to ensure full shift coverage was available for 1st aid and CPR certified staff during the week of August 14-20, 2023. |
| Failed to ensure annual in-service training was provided for 2 of 5 employees reviewed. |
| Failed to obtain a copy and/or order a new chest x-ray for a resident (Resident H). |
| Failed to ensure a tuberculosis infection prevention program was in place by utilization of the two-step skin test and/or alternative laboratory testing for 3 of 5 residents reviewed (Residents B, G, and H). |
Report Facts
Residential Census: 35
Observations lacking 1st aid/CPR coverage: 10
Employees reviewed: 5
New hires reviewed: 3
Employees lacking annual in-service training: 2
Residents reviewed for chest x-rays: 5
Residents lacking TB skin test or alternative testing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherri Dawson | Executive Director | Signed the report and interviewed during the survey. |
| Qualified Medication Aide 11 | New employee lacking reference checks before hire. | |
| Licensed Practical Nurse 9 | Licensed Practical Nurse | Employee lacking annual in-service training documentation. |
| Certified Nursing Aide 10 | Certified Nursing Aide | Employee lacking annual in-service training documentation. |
| Assistant Director of Nursing | Interviewed regarding chest x-ray and TB skin test deficiencies. | |
| Administrator | Interviewed regarding employee reference checks and TB skin test policy. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Jun 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410248.
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 IN00410248 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 33
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
May 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399755 at Grand Brook Memory Care of Zionsville.
Findings
No deficiencies related to the allegations in Complaint IN00399755 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00399755 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Oct 25, 2022
Visit Reason
This visit was for the investigation of Complaint IN00392567 regarding an involuntary discharge of a resident without proper notice or procedures.
Findings
The facility initiated an involuntary discharge of Resident B without proper 30-day notice or opportunity to appeal, resulting in psychosocial harm. The resident was discharged with a 3-day notice after an alleged sexual assault incident, without documented physician orders, discharge planning, or alternate placement arrangements. The resident's care needs and behaviors were not adequately assessed or documented, and the discharge process did not comply with regulatory requirements.
Complaint Details
Complaint IN00392567 was substantiated. The complaint involved Resident B being discharged involuntarily with a 3-day notice without proper regulatory compliance, causing psychosocial harm. The resident was accused of inappropriate sexual behavior toward a visitor, but no documented behaviors or safety risks were present prior to discharge. The facility did not follow required procedures for discharge notices, physician orders, or discharge planning.
Deficiencies (3)
| Description |
|---|
| Involuntary discharge without reasonable and appropriate notice or opportunity to appeal for Resident B. |
| Failure to provide proper discharge notice including required recipients and documentation. |
| Lack of discharge planning including relocation plan, care plan conference with family, and alternate placement arrangements. |
Report Facts
Residential Census: 33
Discharge notice period: 3
Discharge date: Sep 23, 2022
Survey completion date: Oct 26, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Lopez | VP of Operations and HealthCare | Signed the report. |
| DHC (Director of Healthcare) | Interviewed multiple times regarding discharge process and Resident B's care and discharge. | |
| Executive Director | Involved in discharge decision and process. | |
| QMA 7 | Qualified Medication Aide | Interviewed regarding resident behaviors. |
| QMA 8 | Qualified Medication Aide | Interviewed regarding resident behaviors. |
| ADHC (Assistant Director of Healthcare) | Interviewed regarding Resident B's behaviors and discharge. | |
| Director of Community Relations | Interviewed regarding Resident B's care and discharge. | |
| Director of Operations/Clinical | Interviewed regarding discharge decision and process. | |
| QMA 14 | Qualified Medication Aide | Interviewed regarding Resident B's behaviors. |
| RN 15 | Registered Nurse | Interviewed regarding Resident B's behaviors. |
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