Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Zionsville Meadows during CMS and state inspections, most recent first.
A resident with dementia and brief psychotic disorder was observed wearing a wander guard even though the care team had determined a trial discontinuation was appropriate after she no longer showed exit-seeking behaviors. Her record lacked active or discontinued orders for the device and lacked monitoring parameters, and the DON stated the discontinuation had been missed until after the surveyor observed the resident.
Multiple residents dependent on staff for dental care did not consistently receive oral hygiene services, as evidenced by observations of poor oral health, missing or improperly stored oral care supplies, and dental records noting heavy plaque, inflamed tissues, and gross decay. Staff interviews and documentation confirmed that oral care was expected as part of daily routines, but actual practices did not meet these standards.
Surveyors found that aerosol disinfectant sprays and medications were left unsecured in several resident rooms, including a memory care unit, with items such as disinfectant spray, Febreze, selenium sulfide lotion, and Pepto Bismol accessible and lacking proper storage or physician orders for bedside use. Facility policies required these items to be locked and inaccessible to residents, but these procedures were not followed.
Surveyors identified multiple environmental deficiencies in a secured memory care unit, including chipped and peeling plaster, debris on the floor, detached cove base trim, an exposed electrical outlet near the nurse's desk, and disorganized storage with medical supplies placed directly on the floor. The facility did not provide an environmental safety policy during the survey.
The facility failed to respond to repeated grievances from the resident council regarding cold food, inadequate linens, and staff attitude. Despite multiple complaints, responses were often delayed or ineffective, with issues like uninsulated food carts and insufficient linen supplies contributing to the problems. The facility's policies on addressing grievances were not followed, leading to ongoing resident dissatisfaction.
The facility failed to notify the Ombudsman of hospital discharges for a resident with multiple medical conditions and for 21 out of 34 residents over a year. The facility did not follow its policy requiring monthly notifications, leading to a deficiency.
The facility failed to maintain appropriate food temperatures, with residents repeatedly complaining about cold meals over a 12-month period. Observations during a survey confirmed that food was served below required temperatures, and staff interviews indicated ongoing challenges in resolving the issue despite new systems and equipment.
The facility failed to cover drinks while delivering lunch trays to residents, as observed on multiple occasions. A CNA and the Activity Director were seen carrying trays with uncovered drinks to residents' rooms and the Assisted Dining room, contrary to the facility's policy requiring food and beverages to be covered during transport.
The facility failed to ensure proper PPE use and infection control during a COVID-19 outbreak. Staff did not wear appropriate PPE, such as gowns and gloves, and improperly used masks. The laundry services were also deficient, with poor conditions and improper handling of soiled linens. Additionally, a blood glucose glucometer was not properly disinfected, as it was not kept wet with a disinfectant wipe for the required time.
A resident with mild cognitive impairment and other health issues did not receive requested nail trimming and shaving at the facility. Despite his care plan indicating the need for assistance with ADLs, the resident reported only receiving two showers and requested nail care, which was not provided. Interviews with staff confirmed that nail care should be part of the shower routine, but records showed it was not done on specific dates, violating the facility's policy on resident rights.
The facility failed to ensure bed rail safety and fall interventions for residents, leading to potential accident hazards. A resident had a large gap between the mattress and side rail, exceeding safety requirements, while another resident's mobility bars were improperly adjusted. Additionally, a resident experienced falls due to missing interventions like a 'call before you fall' sign and a scoop mattress, with her call light often out of reach and oxygen concentrator too close to the bed.
A facility failed to manage a dementia resident with a history of aggression, leading to multiple incidents of physical contact with other residents. Despite being admitted to a secured unit, the resident's care plan lacked interventions to address his behavior. This resulted in injuries to another resident, including a fracture, due to inadequate supervision and management of the aggressive resident.
Missing wander guard orders and delayed discontinuation
Penalty
Summary
The facility failed to ensure a resident had orders for a wander guard device and failed to remove the device when it was determined to be unnecessary for one resident reviewed for wander guards. The resident was observed sitting on her bed with a wander guard on her right ankle that appeared to be applied and functioning properly. She stated that when she first admitted to the facility she was very confused and needed to be in the memory care unit, but later improved and moved to a unit with peers on her cognitive level for her social well-being. She pointed to the wander guard and said she was not sure why she still needed it now that she was no longer as confused as before, and said staff had told her it would be removed but it had not been taken off yet. The resident’s record showed diagnoses including dementia and brief psychotic disorder, and a BIMS score of 12 out of 15 indicating moderate cognitive impairment. A progress note documented that the wander guard had been placed to improve safety during the transition from the locked memory care unit to the long-term care unit, with review planned in a few weeks. An IDT note later indicated she had not displayed exit-seeking behaviors and that a trial discontinuation of the wander guard was appropriate, and an elopement assessment stated the device was discontinued. However, the record lacked active or discontinued orders for the wander guard and lacked monitoring parameters for the device. The DON stated the trial discontinuation had been missed and that the device was discontinued only after the surveyor observed the resident, and later presented orders that had been created after the fact.
Failure to Provide Adequate Oral Hygiene for Memory Care Residents
Penalty
Summary
The facility failed to ensure that residents on the secured memory care unit who were dependent on staff for dental care received appropriate oral hygiene services. Observations, interviews, and record reviews revealed that 7 out of 9 residents reviewed for ADL assistance did not consistently receive oral care. Specific findings included residents with visible dental issues such as broken or discolored teeth, plaque buildup, and missing oral care supplies in their rooms. Dental records indicated poor oral hygiene, red and inflamed tissues, heavy plaque, and gross decay in several residents. Despite documentation that oral care was part of daily routines and staff competency checklists included oral hygiene, actual care practices did not align with these standards. Staff interviews confirmed that residents were dependent on staff for daily hygiene, and supplies were reportedly accessible, yet oral care items were often missing or improperly stored in resident rooms. Nursing and dental progress notes documented ongoing dental issues and poor oral hygiene among residents with dementia and other cognitive impairments. The deficiency was further substantiated by an anonymous concern that staff were not brushing residents' teeth, and by direct observations of inadequate oral care supplies and poor oral health conditions among multiple residents.
Unsecured Hazardous Sprays and Medications in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to secure aerosol disinfectant sprays and medications in resident rooms, resulting in potential accident hazards. Specifically, a resident on the secured memory care unit had a large can of disinfectant spray stored openly on a closet shelf, with a caution label indicating it should be locked and warning of hazards if absorbed or inhaled. Another resident with a roommate had a can of Febreze spray left on top of a dresser, also with cautionary instructions. Additionally, a third resident had a bottle of selenium sulfide lotion without a cap on a dresser, and an opened bottle of Pepto Bismol was found at the bedside of a resident who was hospitalized. In both cases, there was no documentation in the clinical record for physician orders allowing medications to be kept at bedside. Facility policies required that all cleaning chemicals be kept in locked storage when not in use and that medications, including treatment items, be stored in locked cabinets or rooms inaccessible to residents and visitors. The policies also specified that medications should not be provided without a physician's order and that bedside medications must be stored in a locked compartment within the resident's room. The observed practices were inconsistent with these policies, as hazardous sprays and medications were left unsecured and accessible in resident rooms.
Environmental Cleanliness and Safety Deficiencies in Memory Care Unit
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, and sanitary environment in one of four hallways, specifically in the secured memory care unit known as Auguste's Cottage. During the initial tour, a PTAC heating and cooling unit in the dining room was found with chipped and peeling plaster board beneath it, and white debris was present on the floor. Additionally, a cove base strip of trim was detached from the wall, exposing chipped paint, and a three-foot section of the trim was lying on the floor near dining room tables where residents walk to be seated. An electrical outlet with a missing face plate was also observed in the hallway near the nurse's desk, within reach of anyone passing by or using a wheelchair. In the supply storage area, supplies were disorganized, with some boxes and medical supplies such as oxygen tubing and bandages stored directly on the floor rather than on pallets. The facility did not provide an environmental safety policy during the survey process.
Facility Fails to Address Repeated Resident Grievances
Penalty
Summary
The facility failed to adequately respond to repeated grievances brought to their attention by the resident council over a period of 7 out of 12 months. The grievances included issues such as cold food, inadequate access to linens, and staff attitude and use of personal devices. Despite these concerns being raised multiple times, the facility did not provide responses for several months, and when responses were given, they were often repetitive and did not lead to lasting solutions. Residents expressed ongoing dissatisfaction, particularly with the temperature of the food, access to linens, and the demeanor of staff, which made them feel devalued. Observations and interviews revealed specific instances contributing to these grievances. For example, a dietary aide was seen using an uninsulated cart to transport food trays, which could contribute to the cold food complaints. Additionally, a blue insulated room tray cart was observed to be in disrepair, lacking a door, which was noted by a CNA as a potential reason for the cold food. The housekeeping supervisor acknowledged the linen supply as a constant complaint and noted that the linen closets were not fully stocked, with some linens being thin and worn. The facility's policies on resident council and grievances were reviewed, indicating that concerns should be addressed by the appropriate department and resolved promptly. However, the facility's actions did not align with these policies, as evidenced by the lack of timely and effective responses to the resident council's repeated concerns. The Activity Director noted difficulties in obtaining responses from departments and acknowledged that some issues, such as staff attitude, might be related to cultural and language barriers, which had not been addressed with the nursing staff.
Failure to Notify Ombudsman of Hospital Discharges
Penalty
Summary
The facility failed to ensure that the Ombudsman received timely notifications of hospital discharges for residents, which is a requirement for proper communication and advocacy. Specifically, the facility did not send end-of-the-month hospital discharge information to the Ombudsman for four hospitalization discharges of a resident and did not notify the Ombudsman of hospital discharges for 21 out of 34 residents from October 26, 2023, to October 24, 2024. This lapse in communication was identified during an internal survey conducted by the facility in September 2024. Resident 14, who had multiple medical conditions including chronic obstructive pulmonary disease, emphysema, and dysphagia, experienced four hospitalizations within the specified period. The facility's Regional Director of Clinicals and Social Services Director confirmed that the required notifications were not sent to the Ombudsman, as the facility had not been following its policy on emergency transfer notifications. The policy required that the Census Activity Report be faxed or mailed to the state Ombudsman each month, which was not adhered to, leading to the deficiency.
Ongoing Issues with Food Temperature in Facility
Penalty
Summary
The facility failed to ensure that food was served at appropriate temperatures, as evidenced by repeated complaints from residents and observations during a survey. The Resident Council Minutes revealed ongoing concerns about cold food temperatures over a span of 12 months, with specific months lacking documented responses from the facility. During a Resident Council meeting, residents confirmed that the issue of cold food persisted despite assurances from the facility that measures were being taken to address it. Observations during the survey showed that a meal cart was left open, and food temperatures were below the required levels, with hot foods not reaching the necessary 140 degrees Fahrenheit and cold foods exceeding the maximum 41 degrees Fahrenheit. Interviews with facility staff, including the Activity Director, Certified Dietary Manager, and Dietary Manager, indicated awareness of the issue but highlighted ongoing challenges in resolving it. The facility had implemented a new heat on demand system and new meal carts, but these measures had not fully addressed the problem. The Executive Director noted that the dietary manager was new and not yet part of the Quality Assurance Performance Improvement team. The facility's policy on food temperatures was reviewed, which outlined the required temperature standards for hot and cold foods, but the policy was not effectively implemented, as evidenced by the survey findings.
Uncovered Drinks During Meal Service
Penalty
Summary
The facility failed to ensure that drinks were covered while providing lunch trays to residents on the 200 hall. This deficiency was observed during lunch service for four residents. On two separate occasions, a Certified Nursing Aide (CNA) was seen carrying lunch trays with uncovered drinks to the rooms of two residents. Additionally, the Activity Director was observed carrying a lunch tray with an uncovered drink to another resident's room and then to the Assisted Dining room. The facility's current policy, titled 'Meal Service and Distribution,' requires that prepared food and beverage items be covered when transported over a distance, such as down a hall or to another unit. This policy was not adhered to during the observed incidents.
Inadequate Infection Control and PPE Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and contact tracing during a COVID-19 outbreak. Staff were observed not wearing appropriate PPE, such as gowns and gloves, when providing care to residents under enhanced barrier precautions. Additionally, staff were seen improperly using masks, such as wearing an N95 mask over a surgical mask, which compromised the effectiveness of the PPE. The Infection Preventionist (IP) acknowledged these breaches and indicated that the facility had a COVID-19 outbreak, but the contact tracing process was incomplete, with missing information on close contacts and outbreak testing plans. The facility also failed to follow appropriate infection prevention procedures in the laundry services. The laundry room was observed to be in poor condition, with peeling paint, debris, and rusted equipment. Staff handling soiled linens did not wear proper PPE, such as gowns, and did not perform hand hygiene after handling contaminated items. The soiled linen was not properly contained, with bags left open to the air, increasing the risk of contamination. The housekeeping staff were unaware of the correct procedures for handling and sanitizing COVID-19 positive linens. Additionally, the facility did not ensure proper cleaning of medical equipment, as observed with the cleaning of a blood glucose glucometer. The glucometer was not kept wet with a disinfectant wipe for the required contact time to ensure effective disinfection. This oversight was confirmed by the Assistant Director of Nursing, who stated that the glucometer needed to remain wet for three minutes to be properly sanitized.
Failure to Provide Requested Nail Trimming and Shaving
Penalty
Summary
The facility failed to ensure that a resident received the requested and desired nail trimming and shaving. Resident 135, who has mild cognitive impairment, glaucoma, and a history of myocardial infarction, required assistance with activities of daily living (ADLs) due to his medical conditions. His care plan indicated he needed help with bathing, dressing, grooming, and hygiene. However, during interviews, Resident 135 expressed that he had only received two showers since his arrival at the facility and had requested staff to cut his fingernails and toenails, particularly on his right foot, which were observed to be discolored and long. The Regional Nursing Consultant and a Certified Nursing Aide (CNA) confirmed that nail care should be part of the resident's shower routine, and the CNA admitted to not providing nail cutting during the shower. Additionally, the Registered Nurse (RN) indicated that CNAs should trim nails and shave residents during showers, and if there was a delay, it should be done the same day. However, the shower sheets for Resident 135 indicated that no nail care was provided on specific dates, and he was not shaved on two occasions. The facility's policy on resident rights emphasized respect, dignity, and the right to make choices about significant aspects of life, including bathing, which was not adhered to in this case.
Failure to Ensure Bed Rail Safety and Fall Interventions
Penalty
Summary
The facility failed to prevent potential accidents by not ensuring that bed rails and mobility devices were appropriately monitored and adjusted to reduce the risk of entrapment for two residents. Resident 67 was observed with a large gap between the mattress and the side rail, which was measured to be 5 inches wide, exceeding the safety requirement of not more than 4 and 3/4 inches. The resident's care plan did not include routine assessments or monitoring of the side rails for safety. Similarly, Resident 32 had a gap of 5 and a half inches on one side of the bed, which was too wide, and there was no documentation of initial or ongoing assessments for the safety of the mobility bars. The facility also failed to ensure fall interventions were in place for another resident, Resident 27, who was observed with bruising on her face and legs due to falls. The resident's room lacked a 'call before you fall' sign, and her call light was often out of reach. Despite previous falls and interventions noted in her care plan, such as a scoop mattress and non-skid strips, these were not implemented. The resident's oxygen concentrator was placed too close to the bed, posing a risk of injury during falls. The deficiencies highlight a lack of adherence to safety protocols and monitoring procedures for bed rails and fall prevention measures. The facility's failure to implement and document necessary safety interventions and assessments contributed to the potential for accidents and injuries among the residents.
Failure to Manage Aggressive Behavior in Dementia Resident
Penalty
Summary
The facility failed to adequately manage and supervise a resident with dementia and a known history of aggressive behaviors. Resident L, diagnosed with Alzheimer's disease and dementia with severe mood and psychotic disturbances, had multiple aggressive episodes towards other residents. Despite being admitted to a secured memory care unit, the facility did not initiate a person-centered care plan upon admission to address Resident L's aggressive behaviors. The resident's record lacked documentation of interventions to assist staff in managing his behavior, leading to several incidents where Resident L made physical contact with other residents, causing injuries. Resident L had a history of aggressive behavior, including a recent hospitalization for psychosis and agitation. After returning to the facility, he had an aggressive episode with a female resident, leading to another psychiatric hospital stay. Despite these incidents, the facility did not implement a comprehensive care plan to prevent further aggressive behavior. Observations showed Resident L propelling himself in a wheelchair and becoming agitated when redirected by staff, resulting in physical altercations with other residents. Resident K, another resident with dementia, suffered a fracture of the left ulnar shaft after an altercation with Resident L. The facility's failure to manage Resident L's behavior and protect other residents resulted in Resident K's injury. The facility's behavior management policy required care plans for residents with problematic behaviors, but no such plan was in place for Resident L, highlighting a deficiency in the facility's management of residents with aggressive behaviors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Hoosier Village | 2 mi | ★★★★★ | 0 | 0 |
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| Restoracy Of Whitestown, The | 4.5 mi | ★★★★★ | 5 | 0 |
| St Augustine Home For The Aged | 4.8 mi | ★★★★★ | 0 | 0 |
| Spring Mill Meadows | 5 mi | ★★★★★ | 4 | 0 |
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