Inspection Reports for Grand Brook Memory Care of Greenwood
2444 S State Rd 135, Greenwood, IN 46143, United States, IN, 46143
Back to Facility ProfileInspection 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/yearDeficiencies per year
8
6
4
2
0
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
Inspection Report
Renewal
Census: 22
Deficiencies: 0
Date: 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
Date: Sep 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443451.
Complaint Details
Complaint IN00443451 was investigated and found to have no deficiencies related to the allegations.
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.
Inspection Report
Renewal
Census: 23
Deficiencies: 5
Date: 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)
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
| Name | Title | Context |
|---|---|---|
| Milissa Downs | Executive Director | Provided fire drill reports, facility policies, and interviews related to deficiencies |
| Director of Health Services | Provided facility fire procedure, clinical record reviews, and interviews related to deficiencies |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Date: Dec 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423834.
Complaint Details
Complaint IN00423834 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations regarding the complaint.
Report Facts
Residential Census: 23
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420012.
Complaint Details
Complaint IN00420012 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00420012 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 5
Date: Mar 1, 2023
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00402041.
Complaint Details
Complaint IN00402041 was substantiated but no deficiencies related to the allegations were cited.
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.
Deficiencies (5)
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
| Name | Title | Context |
|---|---|---|
| Brittany McKinney | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Caregiver 1 | Observed transferring Resident 2 without gait belt and performing perineal care without proper hand hygiene | |
| Caregiver 2 | Observed performing perineal care without proper hand hygiene | |
| Caregiver 3 | Observed transferring Resident 2 without gait belt and interviewed about gait belt availability | |
| Director of Quality & Training | Corporate Director of Quality and Training | Provided facility policies and interviews regarding postings and survey book accessibility |
| Assistant Director of Nursing | Provided facility policy on transfers | |
| Director of Nursing | DON | Indicated proper hand hygiene and glove change were required during perineal care |
| Director of Community Relations | Provided infection control policy |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00392764, IN00396022, and IN00398189.
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.
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.
Report Facts
Complaint investigations: 3
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00385858.
Complaint Details
Complaint IN00385858 was unsubstantiated due to lack of evidence.
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.
Viewing
Loading inspection reports...
