Inspection Reports for Brickyard Healthcare – Bloomington Care Center
IN, 47401
Back to Facility ProfileDeficiencies per Year
28
21
14
7
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 111
Capacity: 111
Deficiencies: 0
Jun 26, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462236.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00462236 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 111
Census Payor Type Medicaid: 92
Census Payor Type Other: 19
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 3, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Brickyard Healthcare - Bloomington Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 115
Capacity: 115
Deficiencies: 0
May 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459143.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00459143 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 115
Total census: 115
Medicare census: 1
Medicaid census: 93
Other payor census: 21
Inspection Report
Routine
Census: 122
Capacity: 153
Deficiencies: 26
May 5, 2025
Visit Reason
Routine emergency preparedness and life safety code recertification survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found not in compliance with emergency preparedness requirements due to failure to maintain weekly generator inspection records, incomplete generator load testing, and lack of documentation for a 4-hour load test. Life safety code deficiencies included obstructed exit doors, improperly maintained courtyard gate keypad, uneven and obstructed exit discharge walkways, inadequate exit lighting, missing or damaged exit signage, unprotected stairway doors, combustible storage in egress corridors, improperly maintained kitchen fire suppression system, incomplete fire watch policies, missing sprinkler coverage in dumbwaiter shaft, corroded sprinkler heads, incomplete sprinkler system documentation, faded fire department connection signage, incomplete fire drill documentation, missing annual fire door inspections, and incomplete testing and documentation of patient care related electrical equipment.
Deficiencies (26)
| Description |
|---|
| Failed to maintain written record of weekly generator inspections for 21 of 52 weeks. |
| Failed to exercise generator monthly with required load and annually with load bank test. |
| Failed to provide documentation of a 4-hour load test of emergency generator within past 36 months. |
| Two exit doors obstructed by metal chairs blocking egress. |
| Keypad to courtyard gate was improperly maintained with exposed wires. |
| Sidewalks at exit discharge areas had gaps, grade changes, and obstructions with rocks and mud. |
| Inadequate lighting along exit means of egress sidewalks. |
| Exit signage missing or damaged in courtyard exits. |
| Station 2 back hall stairway door lacked fire rating and self-closing feature. |
| Combustible materials stored in egress corridor in lower level/basement. |
| Storage room door in lower level lacked properly connected self-closing device. |
| Kitchen staff not instructed on proper use of UL 300 hood fire suppression system. |
| No approved method to ensure kitchen cooking appliances are returned to approved design location under hood suppression system. |
| Incomplete fire watch policies for sprinkler system out of service. |
| No sprinkler coverage in dumbwaiter shaft. |
| Sprinkler heads in multiple locations covered with corrosion or paint and not replaced. |
| Incomplete documentation of sprinkler system inspections and maintenance. |
| Fire department connection sign faded and not visible; no directional signage provided. |
| Incomplete fire protection system impairment policies. |
| REM Unit Activity Room open to corridor without smoke detector or door, not supervised by 24-hour station. |
| Missing quarterly fire drill documentation for 2 of 3 shifts during 2 quarters; inaccurate shift times documented for 8 of 13 fire drills. |
| No documentation of annual inspection and testing of all fire door assemblies. |
| Failed to maintain written record of weekly generator inspections for 21 of 52 weeks (repeated). |
| Failed to exercise generator monthly with required load and annually with load bank test (repeated). |
| Failed to provide documentation of a 4-hour load test of emergency generator within past 36 months (repeated). |
| Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE). |
Report Facts
Certified beds: 153
Census: 122
Weeks without documentation: 31
Months without load bank test: 12
Fire drills missing documentation: 2
Fire drills with inaccurate shift times: 8
Sprinkler heads replaced: 5
Fire door assemblies inspected: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Oliver | VP Regulatory Compliance | Signed the inspection report |
| Executive Director | Participated in interviews and exit conference | |
| Maintenance Director | Participated in interviews, acknowledged findings, and exit conference | |
| Maintenance Assistant | Observed during keypad inspection | |
| Cook | Interviewed regarding kitchen fire suppression system |
Inspection Report
Annual Inspection
Census: 118
Capacity: 118
Deficiencies: 5
Apr 25, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00457404.
Findings
The facility was found deficient in several areas including failure to provide written notification for transfer/discharge and bed hold policy to a resident and representative, failure to implement fall interventions for a resident at risk for falls, failure to hold insulin per physician orders for a resident, and failure to maintain a safe, functional, sanitary, and homelike environment in secured units and resident rooms.
Complaint Details
Complaint IN00457404 was investigated during this visit and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure written notification for transfer and discharge was provided to resident and representative for 1 of 1 resident reviewed for hospitalization (Resident 53). | SS=D |
| Failed to ensure notification of bed-hold policy was provided in writing to resident or representative for 1 of 1 resident reviewed for hospitalization (Resident 53). | SS=D |
| Failed to ensure care plan fall interventions were in place for a resident at risk for falls for 1 of 4 residents reviewed for accidents (Resident 107). | SS=D |
| Failed to provide care per plan of care for 1 of 5 residents reviewed for unnecessary medications; insulin was not held per physician's orders (Resident 107). | SS=D |
| Failed to provide a homelike environment free of damage, disrepair, and odor of urine for 1 of 2 secured units and 5 of 7 resident rooms reviewed for environment (Reflections 2 Unit and Rooms 43, 44, 45, 47, 48). | SS=E |
Report Facts
Census: 118
Total Capacity: 118
Deficiencies cited: 5
Records reviewed per week: 10
Records reviewed per week: 5
Monitoring duration: 2
Monitoring duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zachary Wilson | Administrator | Signed the report and provided facility policies |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding deficiencies, provided policies, and responsible for monitoring corrective actions |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding fall interventions for Resident 107 |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding fall interventions for Resident 107 |
| Maintenance Supervisor | Responsible for addressing environmental concerns and conducting monthly inspections | |
| Director of Admissions | Provided Resident Rights document |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 125
Deficiencies: 1
Apr 2, 2025
Visit Reason
The visit was conducted as an investigation of Complaint IN00456505 regarding substandard quality of care and resulted in a Partially Extended Survey with Immediate Jeopardy.
Findings
The facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of exit seeking from eloping the facility unnoticed, resulting in Immediate Jeopardy. The resident was found 1.8 miles away by local law enforcement. The Immediate Jeopardy was removed after corrective actions were implemented.
Complaint Details
Complaint IN00456505 was substantiated with federal and state deficiencies cited related to allegations of substandard quality of care and failure to prevent elopement.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide supervision to prevent a cognitively impaired resident from exiting the facility without staff knowledge, resulting in elopement. | Immediate Jeopardy |
Report Facts
Resident census: 125
Total licensed capacity: 125
Medicare residents: 5
Medicaid residents: 95
Other payor residents: 25
Distance resident eloped: 1.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Interviewed regarding resident elopement incident |
| LPN 2 | Licensed Practical Nurse | Interviewed about resident's secured unit placement and exit seeking behavior |
| LPN 3 | Licensed Practical Nurse | Interviewed about resident's previous exit attempt |
| LPN 4 | Licensed Practical Nurse | Interviewed about resident's frustration on secured unit |
| Area Vice President | Notified of Immediate Jeopardy and provided incident report | |
| Regional Nurse | Notified of Immediate Jeopardy and provided Alzheimer's/Dementia Special Care Unit Disclosure | |
| ADON | Assistant Director of Nursing | Interviewed about resident admission and elopement behaviors |
| Memory Care Director | Interviewed about resident's elopement behaviors on secured unit |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 18, 2025
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00450128 and IN00450202 completed on January 27, 2025.
Findings
Brickyard Healthcare - Bloomington Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the investigations for the two complaints. Both complaints were corrected.
Complaint Details
Investigation of Complaints IN00450128 and IN00450202; both complaints were corrected.
Inspection Report
Complaint Investigation
Census: 128
Capacity: 128
Deficiencies: 2
Jan 27, 2025
Visit Reason
This visit was for the investigation of complaints IN00450128 and IN00450202 concerning federal and state deficiencies related to medication administration and resident records.
Findings
The facility failed to ensure a licensed practical nurse properly administered medications without leaving medications unattended at the bedside for Resident B, and failed to accurately document wound care treatments for Resident C. Both deficiencies were related to complaints and involved failure to follow medication administration and documentation policies.
Complaint Details
The investigation was triggered by complaints IN00450128 and IN00450202. Both complaints resulted in citations at F554 and F842 related to medication administration and resident record documentation. The complaints were substantiated with findings of deficient practices.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a licensed practical nurse observed medication administration and did not leave medications unattended at the bedside for Resident B. | SS=D |
| Failed to ensure staff accurately documented wound care treatments for Resident C. | SS=D |
Report Facts
Census: 128
Total Capacity: 128
Medicare residents: 6
Medicaid residents: 93
Other residents: 29
Medications observed in cup: 8
Medications ordered for Resident B: 11
Dates missing wound care documentation: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Swaby | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
| LPN 1 | Licensed Practical Nurse involved in medication administration observation and re-education | |
| Interim Director of Nursing | Interim Director of Nursing | Provided interviews, policy information, and oversight of corrective actions |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 126
Deficiencies: 0
Dec 19, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446140, IN00446660, IN00449440, and IN00449441 at Brickyard Healthcare - Bloomington Care Center.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaints investigated.
Complaint Details
Complaints IN00446140, IN00446660, IN00449440, and IN00449441 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 126
Total Capacity: 126
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 96
Census Payor Type - Other: 23
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 1
Oct 17, 2024
Visit Reason
This visit was conducted to investigate complaints IN00444190 and IN00444330 regarding alleged abuse at the facility.
Findings
The investigation found no deficiencies related to complaint IN00444190. However, for complaint IN00444330, the facility failed to protect a resident from verbal abuse by a staff member, resulting in a deficiency citation at F600.
Complaint Details
Complaint IN00444190 was not substantiated with any deficiencies. Complaint IN00444330 was substantiated with a deficiency related to verbal abuse by LPN 1 towards Resident C.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to protect a resident's right to be free from verbal abuse by a staff member. | SS=D |
Report Facts
Census: 117
Total Capacity: 117
Medicare Census: 2
Medicaid Census: 100
Other Payor Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Named in verbal abuse finding involving Resident C |
| LPN 2 | Licensed Practical Nurse | Witnessed verbal abuse incident between Resident C and LPN 1 |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interview details about the verbal abuse incident |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
Sep 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443366.
Findings
No deficiencies related to the allegations in Complaint IN00443366 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00443366 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 101
Census Payor Type - Other: 15
Inspection Report
Re-Inspection
Census: 122
Capacity: 153
Deficiencies: 0
Aug 19, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/16/2024.
Findings
At this PSR survey, Brickyard HealthCare - Bloomington Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements, including full sprinklering and smoke detection systems throughout the facility.
Report Facts
Certified beds: 153
Census: 122
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Aug 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439124.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Complaint Details
Complaint IN00439124 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 112
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 97
Census Payor Type Other: 13
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 23, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure Survey was completed.
Findings
Brickyard Healthcare - Bloomington Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 109
Capacity: 153
Deficiencies: 8
Jul 16, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related NFPA codes.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency power system inspections, battery operated smoke alarm maintenance, hazardous area door closures, portable fire extinguisher accessibility, corridor smoke detection, electrical safety including GFCI receptacles and uncovered junction boxes, and generator inspection documentation.
Severity Breakdown
SS=F: 3
SS=D: 3
SS=B: 1
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; missing weekly inspections for 15 weeks. | SS=F |
| Incomplete documentation for preventative maintenance of battery operated smoke alarms in resident rooms; weekly testing not performed as required. | SS=F |
| Failed to ensure 1 of 17 hazardous areas (Laundry room door) was separated by smoke resistant partitions and doors; door failed to latch properly. | SS=D |
| Portable fire extinguisher obstructed by patient lift, not readily accessible. | SS=B |
| Resident seating area open to corridor without electrically supervised automatic smoke detection system as required. | SS=E |
| Failed to ensure all ground fault circuit interrupter (GFCI) receptacles were properly maintained; two receptacles near sink did not trip when tested. | SS=D |
| Electrical junction box without cover and exposed wiring noted in kitchen sprinkler riser room. | SS=D |
| Failed to maintain written records of weekly generator inspections for 15 of 52 weeks. | SS=F |
Report Facts
Certified beds: 153
Census: 109
Missing weekly inspections: 15
Hazardous areas assessed: 17
Residents affected by fire extinguisher obstruction: 28
Residents affected by corridor smoke detection deficiency: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Swaby | Executive Director | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to findings, interviews, and corrective actions |
Inspection Report
Annual Inspection
Census: 110
Capacity: 110
Deficiencies: 6
Jun 24, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00436387.
Findings
The facility was found deficient in several areas including failure to ensure self-medication administration assessments, failure to provide written notice of transfer/discharge and bed-hold policy to residents and representatives, lack of ongoing communication with dialysis center, administration of medications outside physician order parameters, and incomplete neurological assessments after an unwitnessed fall.
Complaint Details
Complaint IN00436387 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a self medication administration assessment was complete for residents with medications left at bedside. | D |
| Failed to provide written notification required for transfer/discharge to resident and representative for 2 of 3 residents reviewed. | D |
| Failed to provide notification of bed-hold policy in writing to resident or representative for 2 of 3 residents reviewed for hospitalization. | D |
| Failed to have ongoing communication with dialysis center regarding dialysis care for 1 of 1 residents reviewed for dialysis care. | D |
| Failed to ensure medications were administered with adequate indications for use; medications administered outside physician order parameters for 1 of 5 residents reviewed. | D |
| Failed to ensure staff documented neurological assessments for 1 of 1 residents reviewed for falls. | D |
Report Facts
Census SNF/NF beds: 110
Census Medicare: 4
Census Medicaid: 95
Census Other: 11
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lana Ballard | Area Vice President/HFA | Signed the report |
| Director of Nursing Services | Interviewed regarding medication administration, transfer/discharge notices, bed-hold policy, and medication administration practices | |
| Assistant Director of Nursing Services | Interviewed regarding dialysis communication | |
| Registered Nurse 1 | Interviewed regarding blood pressure monitoring and medication holding parameters |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
May 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432450 and IN00433284.
Findings
No deficiencies related to the allegations in complaints IN00432450 and IN00433284 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00432450 and IN00433284 found no deficiencies related to the allegations.
Report Facts
Medicare census: 5
Medicaid census: 94
Other payor census: 13
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 29, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00430007 completed on April 2, 2024.
Findings
Brickyard Healthcare - Bloomington Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00430007 completed on April 2, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 116
Capacity: 116
Deficiencies: 1
Apr 2, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429746 and IN00430007. Complaint IN00429746 had no deficiencies related to the allegations, while Complaint IN00430007 resulted in federal/state deficiencies being cited.
Findings
The facility failed to prevent a fall when staff did not use a gait belt to transfer a resident dependent on staff for transfers (Resident B). Staff were re-educated on gait belt use and corrective actions were implemented to prevent recurrence.
Complaint Details
Complaint IN00429746 - No deficiencies related to the allegations are cited. Complaint IN00430007 - Federal/State deficiencies related to the allegations are cited at F689.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to prevent a fall when staff did not use a gait belt to transfer a resident dependent on staff for transfers. | SS=D |
Report Facts
Census: 116
Total Capacity: 116
Residents reviewed for falls: 3
Medicare residents: 4
Medicaid residents: 96
Other payor residents: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Swaby | Executive Director | Signed the report |
| CNA 1 | Certified Nursing Aide | Named in fall incident and failure to use gait belt |
| CNA 2 | Certified Nursing Aide | Named in fall incident and failure to use gait belt |
| DON | Director of Nursing | Provided policy and confirmed gait belt use requirement |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 0
Feb 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428257.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00428257 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 120
Total Capacity: 120
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 100
Census Payor Type Other: 15
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 0
Feb 6, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00425766, IN00426963, and IN00427276.
Findings
No deficiencies related to the allegations in complaints IN00425766, IN00426963, and IN00427276 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00425766, IN00426963, and IN00427276 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 120
Total Census: 120
Medicare Census: 5
Medicaid Census: 100
Other Payor Census: 15
Inspection Report
Complaint Investigation
Census: 123
Capacity: 123
Deficiencies: 0
Nov 21, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00421434 and IN00421115.
Findings
No deficiencies related to the allegations in complaints IN00421434 and IN00421115 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00421434 - No deficiencies related to the allegations are cited. Complaint IN00421115 - No deficiencies related to the allegations are cited.
Report Facts
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 98
Census Payor Type - Other: 19
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
Oct 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418913.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00418913 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census SNF/NF: 119
Census Payor Type Medicare: 3
Census Payor Type Medicaid: 103
Census Payor Type Other: 13
Inspection Report
Re-Inspection
Census: 116
Capacity: 153
Deficiencies: 0
Sep 12, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/08/23 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Brickyard Healthcare - Bloomington Care Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 153
Census: 116
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 25, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on July 24, 2023.
Findings
Brickyard Healthcare - Bloomington Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 116
Capacity: 153
Deficiencies: 7
Aug 8, 2023
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency lighting testing documentation, battery operated smoke alarm maintenance, fire extinguisher inspections, corridor door latching, boiler inspection certificates, fire drill documentation, and emergency generator testing and maintenance.
Severity Breakdown
SS=F: 3
SS=C: 2
SS=D: 1
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure complete documentation for monthly testing of battery backup emergency lighting for 30 seconds over the past 12 months. | SS=F |
| Failed to ensure complete documentation for preventative maintenance of battery operated smoke alarms in resident rooms for the last 12 months. | SS=C |
| Failed to inspect 1 of 1 portable fire extinguishers in the Activity Center monthly; missing monthly inspection documentation from February to August 2023. | SS=D |
| Failed to ensure 2 of over 50 corridor doors had no impediment to closing and latching, affecting doors to resident rooms 136 and 102. | SS=E |
| Failed to ensure 2 fuel-fired boilers had current inspection certificates; certificates expired 02/01/22. | SS=C |
| Failed to provide documentation of fire drills conducted on the third shift for 2 of 4 quarters. | SS=F |
| Failed to document 36-month emergency generator testing for 4 continuous hours and maintain complete written records of monthly generator load testing and weekly inspections. | SS=F |
Report Facts
Certified beds: 153
Census: 116
Deficiencies cited: 7
Fire extinguisher inspections missed: 7
Fire drills missing: 2
Emergency generator testing interval: 36
Emergency generator weekly inspections missed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Swaby | Executive Director | Named in relation to exit conferences and review of findings |
| Maintenance Director | Named in relation to findings and interviews about deficiencies |
Inspection Report
Annual Inspection
Census: 115
Capacity: 115
Deficiencies: 3
Jul 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 18 to July 24, 2023.
Findings
The facility was found deficient in accurately reflecting residents' Minimum Data Set (MDS) assessments, implementing nutrition and hydration interventions for residents with significant weight loss, and maintaining sanitary food storage conditions in the kitchen, including issues with freezer and refrigerator door seals.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' status for 2 of 3 residents reviewed. | SS=D |
| Failed to ensure staff implemented new weight loss interventions for a resident with assessed significant weight loss. | SS=D |
| Failed to ensure food was stored in a sanitary manner; food stored beneath a freezer water line with condensation and ice, and walk-in freezer and refrigerator door seals were in disrepair. | SS=E |
Report Facts
Census: 115
Total Capacity: 115
Weight loss percentage: 22.8
Weight loss percentage: 26
Weight loss percentage: 14.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Swaby | Executive Director | Signed the inspection report |
| Director of Nursing Services | Provided information about Resident 3's weight loss interventions and facility policies | |
| Dietary Manager | Interviewed regarding food storage and kitchen conditions | |
| Corporate Dietary Manager | Interviewed regarding facility food safety policies |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 118
Deficiencies: 0
Apr 12, 2023
Visit Reason
This visit was conducted for the investigation of four complaints: IN00401449, IN00404106, IN00404200, and IN00405076.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with applicable federal and state regulations regarding the complaints investigated.
Complaint Details
Complaints IN00401449, IN00404106, IN00404200, and IN00405076 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 118
Total Capacity: 118
Medicare Census: 9
Medicaid Census: 99
Other Payor Census: 10
Inspection Report
Re-Inspection
Census: 116
Capacity: 116
Deficiencies: 0
Mar 14, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00397138, IN00399885, IN00400312, IN00400730, and IN00400735 completed on February 10, 2023.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the Post Survey Revisit to the Investigation of Complaints. All cited complaints were corrected.
Complaint Details
The visit was related to complaints IN00397138, IN00399885, IN00400312, IN00400730, and IN00400735. All complaints were corrected as of this visit.
Report Facts
Census Bed Type: 116
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 97
Census Payor Type - Other: 11
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 4
Feb 7, 2023
Visit Reason
This visit was for the investigation of multiple complaints and included a COVID-19 Focused Infection Control Survey.
Findings
The facility was found to have multiple deficiencies including failure to provide reasonable accommodations for resident needs, failure to protect residents from physical abuse, failure to provide adequate activities on the secured memory care unit, and failure to maintain kitchen cleanliness.
Complaint Details
Complaints IN00397138, IN00399885, IN00400312, IN00400730, IN00400735 were substantiated with related federal/state deficiencies cited. Complaint IN00401386 was unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 1
SS=G: 1
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide reasonable accommodations of resident needs for 1 of 3 residents reviewed (Resident B) related to bed positioning. | SS=D |
| Failed to protect the resident's right to be free from physical abuse for 1 of 3 residents reviewed (Resident C and Resident D altercation). | SS=G |
| Failed to provide activities to residents residing on a secured memory care unit affecting 28 residents. | SS=E |
| Failed to ensure the kitchen floor was cleaned properly during 1 kitchen observation. | SS=E |
Report Facts
Census: 119
Total Capacity: 119
Complaint IDs: 6
Residents affected by memory care activity deficiency: 28
Residents reviewed for reasonable accommodations: 3
Residents reviewed for abuse: 3
Audit frequency for abuse monitoring: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Swaby | Executive Director | Signed report |
| LPN 1 | Licensed Practical Nurse | Nurse on duty during resident altercation |
| Social Service Director | Interviewed regarding resident altercation | |
| Administrator | Provided policies and information on bed positioning and activities | |
| Maintenance Supervisor | Interviewed about bed positioning directives | |
| Unit Manager | Interviewed about bed positioning directives | |
| LPN 2 | Licensed Practical Nurse | Interviewed about activities on memory care unit |
| Activity Director | Interviewed about activities on secured memory care unit | |
| Activity Assistant | Interviewed about activities on secured memory care unit | |
| Cook 1 | Interviewed about kitchen cleanliness |
Inspection Report
Re-Inspection
Census: 132
Capacity: 132
Deficiencies: 0
Jan 17, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00395664 completed on December 5, 2022.
Findings
Brickyard Healthcare - Bloomington Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00395664.
Complaint Details
Complaint IN00395664 - Corrected.
Report Facts
Census SNF/NF beds: 132
Census Medicare residents: 12
Census Medicaid residents: 109
Census Other residents: 11
Total Census: 132
Inspection Report
Complaint Investigation
Census: 125
Capacity: 125
Deficiencies: 2
Dec 5, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00395599 and IN00395664. Complaint IN00395599 was unsubstantiated due to lack of evidence, while Complaint IN00395664 was substantiated with related federal/state deficiencies cited.
Findings
The facility failed to provide a sanitary environment in 8 of 20 rooms reviewed, with dirt, debris, and grime buildup noted. Additionally, the facility failed to maintain an effective pest control program, with live and dead cockroaches observed in 3 of 20 rooms.
Complaint Details
Complaint IN00395599 was unsubstantiated due to lack of evidence. Complaint IN00395664 was substantiated with federal/state deficiencies cited at F921 and F925.
Severity Breakdown
E: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, with dirt, debris, and grime buildup in multiple resident rooms. | E |
| Failed to maintain an effective pest control program; live and dead cockroaches were found in resident rooms. | D |
Report Facts
Census: 125
Total Capacity: 125
Medicare Census: 8
Medicaid Census: 102
Other Payor Census: 15
Rooms with unsanitary conditions: 8
Rooms with pest issues: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott A Swaby | Executive Director | Signed the report |
| Licensed Practical Nurse (LPN 1) | Indicated housekeeping cleaned rooms daily but floor should have been cleaned | |
| Housekeeping Supervisor | Indicated housekeepers cleaned under beds once a month; rest of floor and baseboards should be cleaned daily | |
| Certified Nursing Aide (CNA 1) | Reported seeing cockroaches in resident rooms | |
| Director of Nursing | Acknowledged awareness of cockroach issue and ineffective prior pest control efforts | |
| Regional Director of Nursing | Provided facility policies on cleaning and pest control |
Inspection Report
Re-Inspection
Census: 110
Capacity: 110
Deficiencies: 0
Nov 10, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00392139 completed on October 17, 2022, conducted in conjunction with the PSR to the Investigation of Complaint IN00387295 completed on September 9, 2022.
Findings
Brickyard Healthcare - Bloomington Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00392139. Both complaints were corrected.
Complaint Details
Complaint IN00392139 and Complaint IN00387295 were investigated and found to be corrected.
Report Facts
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 96
Census Payor Type - Other: 9
Inspection Report
Re-Inspection
Census: 110
Capacity: 110
Deficiencies: 0
Nov 10, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00387295 completed on September 9, 2022, and in conjunction with the PSR to the Investigation of Complaint IN00392139 completed October 17, 2022.
Findings
Brickyard Healthcare - Bloomington Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00387295. Both complaints IN00387295 and IN00392139 were corrected.
Complaint Details
This visit was related to complaint investigations IN00387295 and IN00392139. Both complaints were found to be corrected.
Report Facts
Census SNF/NF beds: 110
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 96
Census Payor Type - Other: 9
Inspection Report
Complaint Investigation
Census: 116
Capacity: 116
Deficiencies: 1
Oct 17, 2022
Visit Reason
This visit was for the investigation of Complaints IN00392139 and IN00392463. Complaint IN00392139 was substantiated with related deficiencies cited, while Complaint IN00392463 was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure food was served in a sanitary manner during one of two kitchen observations, with food and supplies found on the floor, a bucket of dirty water present, and sticky floors. Corrective actions included cleaning, repairs, repainting, and staff education on sanitation and cleaning protocols.
Complaint Details
Complaint IN00392139 was substantiated with federal/state deficiencies cited at F812. Complaint IN00392463 was unsubstantiated due to lack of evidence.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure food was served in a sanitary manner; food and supplies were on the floor, a bucket of dirty water was observed, and the floor was sticky. | SS=E |
Report Facts
Census: 116
Total Capacity: 116
Medicare Census: 5
Medicaid Census: 96
Other Payor Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Swaby | Executive Director | Named as facility representative during inspection and in plan of correction |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 114
Deficiencies: 1
Sep 9, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00386492 and IN00387295 and included a COVID-19 Focus Infection Control Survey.
Findings
Complaint IN00386492 was unsubstantiated due to lack of evidence. Complaint IN00387295 was substantiated with federal/state deficiencies cited related to food palatability and presentation. The facility failed to provide food that was palatable and attractive to 4 of 5 residents interviewed.
Complaint Details
Complaint IN00386492 was unsubstantiated due to lack of evidence. Complaint IN00387295 was substantiated with deficiencies cited at F804 related to food palatability and presentation.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide food that was palatable and attractive to residents, including tough chicken, bland macaroni and cheese, bland zucchini bake, and watery ambrosia dessert. | SS=E |
Report Facts
Census: 114
Total Capacity: 114
Medicare Residents: 5
Medicaid Residents: 104
Other Payor Residents: 5
Inspection Report
Life Safety
Deficiencies: 0
Jul 7, 2022
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey.
Findings
Golden Living Center - Bloomington was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
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