Zionsville Meadows

In the surveyor’s words

From the most serious findings on record at Zionsville Meadows, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 28, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident on dual antiplatelet therapy who had a fall from bed, landed on her face, and sustained a visible head injury was assessed for a change in condition and promptly sent to the hospital for 1 of 3 residents reviewed for accidents (Resident B). The immediate Jeapardy began on [DATE], at approximately 8:00 p.m., when Resident B with previous history of cerebrovascular accident (CVA, commonly called a stroke is a condition where blood flow to a part of the brain is blocked or a blood vessel bursts, causing brain cells to die from a lack of oxygen), subdural hemorrhage in December of 2025, and was taking two antiplatelets (drugs that stop blood cells from sticking together), rolled off her bed during… […]

• Immediate jeopardy, isolatedF686Jul 6, 2022

  Based on observation, record review, and interview, the facility failed to identify wounds, and complete skin assessments for 1 of 3 residents resulting in the resident developing a stage 3 pressure ulcer (a pressure ulcer which involved epidermis, dermis, and subcutaneous tissue and was a full thickness loss) to the sacrum before being identified which worsened to a stage 4 pressure ulcer (an ulcer which involved epidermis, subcutaneous tissue, bone and other supportive tissue including full thickness skin loss with extensive destruction of underlying tissue and structures) with [CONDITION(S)] (infection to the bone) requiring hospitalization and surgical debridement and upon arriving to the hospital the resident was found to have Deep Tissue Injuries (a pressure-related injury to… […]

• Actual harm, isolatedF689Aug 28, 2026

  Based on interviews and record review, the facility failed to prevent a fall of a resident with right-sided paralysis when the resident was turned onto her left side and fell out of bed hitting her head on the ground resulting in actual harm when the resident sustained intercerebral hemorrhaging (where a blood vessel bursts inside the brain tissue, causing bleeding that puts pressure on the brain) and bilateral subdural hematoma (a serious and life-threatening condition where blood collects between the surface of the brain and its outer protective lining usually caused by a head injury) for 1 of 3 residents reviewed for accidents (Resident B). The deficient practice was corrected on 8/6/26, prior to the start of the survey, and was therefore past noncompliance. […]

• Actual harm, isolatedF684May 27, 2021

  Based on interview and record review, the facility failed to ensure a resident's legal guardian was immediately notified of a fall with injuries when the resident, who was unable to make decisions for herself, was refusing to go to the emergency room which resulted in actual harm when emergency medical treatment was delayed for the multiple areas of bleeding in the brain, a subdural hematoma (a type of bleed that occurs within the skull of head but outside the actual brain tissue), and arm fracture for 1 of 5 residents reviewed for falls (Resident B). Findings include: During a confidential interview during the survey, the interviewee indicated Resident B had been a long-time dependent user of anticoagulant medication. […]

• No harm, potential for more than minimal, widespreadF812May 27, 2021

  Based on observation, interview, and record review, the facility failed to ensure expired food was not served to residents, food preparation equipment was sanitized properly, a refrigerator was maintained at a safe temperature, and overall kitchen cleanliness was maintained. This had the potential to affect 55 of 55 residents who received food from the kitchen. Findings include: 1. During an initial kitchen tour with the Culinary and Nutrition Manager (DM) on [DATE] 9:17 a.m., the following was observed. A crate of 16 individual-sized cartons of chocolate milk was observed inside of a walk-in refrigerator (prep fridge). The expiration date on each carton of milk was, [DATE]. […]