Inspection Reports for Brickyard Healthcare – Brookview Care Center
7145 E 21ST STREET, INDIANAPOLIS, IN, 46219
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 1, 2025, found the facility in compliance with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to resident care issues such as failure to ensure timely transportation to appointments, incomplete investigations of abuse and misappropriation allegations, and medication and catheter care. Life Safety Code inspections identified multiple issues over time with fire safety equipment, emergency preparedness, and building maintenance, though these were addressed through corrective actions and follow-up surveys. Several complaint investigations were substantiated with deficiencies, while many others were unsubstantiated or found corrected upon revisit. The facility’s inspection history shows some improvement in compliance with recent visits showing no deficiencies after prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
22.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
443% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a cognitively impaired resident (Resident B), assessed as an elopement risk, exited the secured memory care unit unsupervised through a bathroom window and was found at a local gas station, leading to an immediate jeopardy situation.
Complaint Details
The complaint investigation found that Resident B, who was cognitively impaired and assessed as an elopement risk, exited the secured memory care unit through a bathroom window unsupervised. The resident was found at a local gas station and later hospitalized. The immediate jeopardy began on October 1, 2025, and was removed after corrective actions were implemented. The investigation included interviews with staff and family, record reviews, and observations.
Findings
The facility failed to ensure adequate supervision and safety measures to prevent elopement of a cognitively impaired resident who exited through a bathroom window. The resident was found outside in a dangerous area and required hospital care after the incident. The facility had not secured bathroom windows properly, and staff were unaware of the risk posed by open windows. Immediate jeopardy was identified and removed after corrective actions including audits, staff education, and installation of safety blocks on windows.
Deficiencies (1)
Failed to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, specifically allowing a cognitively impaired resident to elope through an unsecured bathroom window.
Report Facts
Residents reviewed for elopement risk: 3
Date Immediate Jeopardy began: Oct 1, 2025
Date Immediate Jeopardy removed: Oct 1, 2025
Distance resident traveled from facility: 0.3
Date of admission to secured memory care unit: Aug 7, 2025
Date of admission MDS assessment: Aug 14, 2025
Date of elopement risk assessment: Aug 15, 2025
Date of behavioral health diagnostic assessment: Sep 2, 2025
Date of general note documenting elopement: Oct 1, 2025
Date of facility observation with Maintenance Supervisor: Oct 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Notified of Immediate Jeopardy and involved in post-incident actions and interviews |
| Director of Nursing | Director of Nursing | Notified of Immediate Jeopardy |
| Corporate Nurse | Corporate Nurse | Notified of Immediate Jeopardy |
| Memory Care Director | Memory Care Director | Interviewed regarding resident's elopement risk and window safety |
| Certified Nurse Aide 4 | Certified Nurse Aide | Reported resident missing and discovered open bathroom window |
| Licensed Practical Nurse 8 | Licensed Practical Nurse | Worked night of elopement, reported missing resident and open window |
| Maintenance Supervisor | Maintenance Supervisor | Observed bathroom window and safety block status post-incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted based on a complaint intake (2572707) to investigate whether the facility ensured appropriate use and care of feeding tubes for residents.
Complaint Details
This citation is related to Intake 2572707.
Findings
The facility failed to ensure that a resident with a gastrostomy feeding tube received water flushes as ordered by the physician. Observations confirmed the feeding pump was set to administer more flush volume than ordered. The facility policy on feeding tube care was reviewed and found to require adherence to physician orders.
Deficiencies (1)
Failed to ensure a resident with a gastrostomy feeding tube received flushes per physician's orders.
Report Facts
Feeding tube flush volume ordered: 50
Feeding tube flush volume observed: 60
Feeding tube feeding rate: 65
Residents reviewed for feeding tubes: 3
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) 2 | Confirmed pump setting for water flushes | |
| Nurse 3 | Confirmed pump setting for water flushes | |
| Director of Nursing | Provided facility policy on feeding tubes |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00462520, IN00462237, and IN00459387, and was in conjunction with a Post Survey Revisit to the investigation of complaint IN00459452 completed on 2025-05-27.
Complaint Details
Complaints IN00462520, IN00462237, and IN00459387 were investigated with no deficiencies cited. The visit also included a Post Survey Revisit to complaint IN00459452 completed on 2025-05-27.
Findings
No deficiencies related to the allegations were cited for complaints IN00462520, IN00462237, and IN00459387. 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 these investigations.
Report Facts
Census: 72
Total Capacity: 72
Medicare Census: 5
Medicaid Census: 43
Other Payor Census: 24
Inspection Report
Re-Inspection
Census: 72
Capacity: 72
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00459452 completed on 2025-05-27, conducted in conjunction with investigations of Complaints IN00462520, IN00462237, and IN00459387.
Complaint Details
This visit was related to the investigation of Complaint IN00459452 and other complaints. Complaint IN00459452 was corrected as of this visit.
Findings
Brickyard Healthcare - Brookview Care Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaint IN00459452. Complaint IN00459452 was corrected.
Report Facts
Census SNF/NF beds: 72
Total census: 72
Medicare census: 5
Medicaid census: 43
Other payor census: 24
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 2
Date: May 27, 2025
Visit Reason
This visit was conducted for the investigation of two complaints, IN00459452 and IN00460111, regarding the facility's compliance with care standards.
Complaint Details
Complaint IN00459452 was substantiated with federal/state deficiencies cited at F684 and F694. Complaint IN00460111 had no deficiencies related to the allegations cited.
Findings
The investigation found no deficiencies related to complaint IN00460111. For complaint IN00459452, deficiencies were cited related to failure to ensure a resident was transported to scheduled appointments and failure to maintain proper orders and care for a resident's intravenous (IV) access.
Deficiencies (2)
Failure to ensure a resident was transported to appointments regarding a tunneled catheter removal.
Failure to ensure a resident with intravenous (IV) access had orders for continued care of the IV access.
Report Facts
Census: 85
Total Capacity: 85
Medicare Residents: 4
Medicaid Residents: 69
Other Residents: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corrine Thompson | Executive Director | Signed the report |
| RN 1 | Registered Nurse | Interviewed regarding transportation issues for Resident B |
| Family Member 2 | Interviewed regarding missed appointments for Resident B | |
| Director of Nursing | DON | Interviewed regarding facility policies and IV care for Resident B |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 27, 2025
Visit Reason
The inspection was conducted in response to a complaint (IN00459452) regarding the facility's failure to ensure a resident was transported to scheduled medical appointments and proper care was provided for intravenous (IV) access.
Complaint Details
This citation is related to Complaint IN00459452.
Findings
The facility failed to transport Resident B to scheduled tunneled catheter removal appointments on 5/6/25 and 5/12/25 due to transportation issues and lack of communication. Additionally, the facility failed to ensure proper orders and documentation for continued care and monitoring of Resident B's IV access.
Deficiencies (2)
Failed to ensure a resident was transported to appointments regarding a tunneled catheter removal.
Failed to ensure a resident with an intravenous (IV) access had orders for continued care for the IV access.
Report Facts
Residents reviewed for appointments: 3
Residents reviewed for IV access: 1
Scheduled tunneled catheter removal appointments missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Interviewed regarding transportation issues for Resident B's appointments. |
| Family Member 2 | Interviewed regarding missed appointments and accompaniment to Resident B's appointments. | |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies and observations related to Resident B's IV access and appointments. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 8, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00454054 completed on March 4, 2025.
Complaint Details
Complaint IN00454054 was investigated and found to be corrected.
Findings
Brickyard Healthcare - Brookview 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 for the complaint survey.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Mar 14, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454878.
Complaint Details
Investigation of Complaint IN00454878 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00454878 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 4
Medicaid census: 54
Other payor census: 21
Inspection Report
Re-Inspection
Census: 82
Capacity: 136
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/16/25 was performed to verify compliance with previous deficiencies.
Findings
At this PSR survey, Brickyard Healthcare-Brookview 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.
Report Facts
Facility capacity: 136
Census: 82
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 4, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding failure to respond to a resident's call light in a timely manner and failure to provide a copy of the facility's bed hold policy prior to transferring a resident to a hospital.
Complaint Details
The citation is related to Complaint IN00454054. The complaint involved failure to respond to a resident's call light from 4:00 a.m. to 7:00 a.m. on 2-20-25 and failure to provide bed hold policy documentation during a hospital transfer.
Findings
The facility failed to ensure timely response to a resident's call light, causing anxiety for the resident, and failed to provide a copy of the bed hold policy to a resident prior to hospital transfer. Staff involved were counseled but not terminated. Education on call light response was ongoing.
Deficiencies (2)
Failed to ensure a resident's call light was responded to in a timely manner, resulting in anxiety for the resident.
Failed to provide a copy of the facility's bed hold policy prior to transferring a resident to an area hospital.
Report Facts
Residents reviewed for staffing: 3
Residents reviewed for transfers: 3
Time call light was unanswered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Named in failure to respond to call light finding; refused to sign counseling document |
| Certified Nurse Aide 5 | Certified Nurse Aide | Named in failure to respond to call light finding; received counseling by phone |
| Director of Nursing | Director of Nursing | Spoke with resident about call light issue and conducted staff counseling |
| Corporate Nurse | Corporate Nurse | Provided grievance form and conducted interview regarding call light response and bed hold policy |
| Registered Nurse 3 | Registered Nurse | Interviewed regarding bed hold policy procedure during hospital transfers |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 2
Date: Mar 3, 2025
Visit Reason
The visit was conducted for the investigation of two complaints, IN00453279 and IN00454054, regarding resident care and facility practices.
Complaint Details
Complaint IN00453279 had no deficiencies related to the allegations. Complaint IN00454054 was substantiated with federal/state deficiencies cited at F550 and F625 related to call light response and bed hold policy notification.
Findings
The investigation found no deficiencies related to complaint IN00453279. For complaint IN00454054, deficiencies were cited related to failure to respond timely to a resident's call light causing anxiety, and failure to provide a resident with the facility's bed hold policy prior to hospital transfer.
Deficiencies (2)
Failure to ensure a resident's call light was responded to in a timely manner, resulting in resident anxiety.
Failure to provide a resident with a copy of the facility's bed hold policy prior to transferring to an area hospital.
Report Facts
Census: 79
Total Capacity: 79
Medicare Residents: 2
Medicaid Residents: 64
Other Residents: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Breque Norris | Executive Director | Signed as facility representative on the report |
| LPN 4 | Licensed Practical Nurse | Named in deficiency related to failure to respond timely to call light; received employee memorandum |
| CNA 5 | Certified Nurse Aide | Named in deficiency related to failure to respond timely to call light; received employee memorandum |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 13, 2025
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of Complaint IN00451414 completed on January 21, 2025.
Complaint Details
Complaint IN00451414 was investigated and found to be corrected.
Findings
Brickyard Healthcare - Brookview 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.
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 2
Date: Jan 21, 2025
Visit Reason
The visit was conducted to investigate two complaints, IN00451414 and IN00451475. Complaint IN00451414 involved federal/state deficiencies related to allegations of abuse and misappropriation of property, while Complaint IN00451475 had no deficiencies cited.
Complaint Details
Complaint IN00451414 was substantiated with deficiencies cited related to abuse and misappropriation of property. Complaint IN00451475 was not substantiated with no deficiencies cited.
Findings
The facility failed to thoroughly investigate an allegation of misappropriation of property for one resident (Resident D) and failed to ensure proper handling and documentation of narcotic pain medication for another resident (Resident E). Specifically, Resident D's investigation did not include interviews related to misappropriation, and Resident E's fentanyl patches were missing with incomplete controlled drug shift audit signatures.
Deficiencies (2)
Failed to thoroughly investigate an allegation of misappropriation of property for Resident D.
Failed to ensure narcotic pain medication was placed in a controlled substance lock box and properly documented during shift audits for Resident E.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for pain medications: 3
Fentanyl patches missing: 4
Medicare census: 3
Medicaid census: 53
Other payor census: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Breque Norris | Area Vice President | Signed the report as Laboratory Director or Provider/Supplier Representative. |
| RN 2 | Received pharmacy delivery of fentanyl patches and involved in medication handling. | |
| RN 3 | Observed with narcotic book and noted missing signatures on controlled drug shift audit forms. | |
| UM 4 | Unit Manager | Indicated facility staff searched for missing fentanyl patches and educated nursing staff on medication sign-in procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 21, 2025
Visit Reason
The inspection was conducted in response to a complaint (IN00451414) regarding allegations of abuse and misappropriation of property involving residents at Brickyard Healthcare - Brookview Care Center.
Complaint Details
This citation is related to Complaint IN00451414. The complaint involved allegations of abuse and misappropriation of property for Resident D and issues with narcotic medication handling for Resident E.
Findings
The facility failed to thoroughly investigate an allegation of misappropriation of property for Resident D and failed to ensure proper handling and documentation of narcotic pain medication for Resident E. Specifically, Resident D's investigation did not include interviews related to misappropriation, and Resident E's fentanyl patches were left unattended and went missing, with incomplete controlled drug shift audit signatures.
Deficiencies (2)
Failed to thoroughly investigate an allegation of misappropriation of property for Resident D.
Failed to ensure narcotic pain medication was placed in a controlled substance lock box upon delivery and ensure proper signing of controlled drug shift audit forms for Resident E.
Report Facts
Missing fentanyl patches: 4
Residents reviewed for abuse: 3
Residents reviewed for pain medications: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Received pharmacy delivery of fentanyl patches and left medications unattended on nurses' station. |
| RN 3 | Registered Nurse | Observed with narcotic book and noted missing signatures on controlled drug shift audit form. |
| UM 4 | Unit Manager | Indicated facility staff searched for missing fentanyl patches and educated nursing staff on medication delivery procedures. |
| Administrator | Provided investigation files and interviews regarding allegations and medication issues. | |
| Pharmacy Technician 10 | Pharmacy Technician | Indicated fentanyl patches were sent to the facility and signed for by RN 2. |
| Corporate Support Health Care Administrator | Provided the Narcotic Pain Patch Policy. |
Inspection Report
Life Safety
Census: 74
Capacity: 136
Deficiencies: 6
Date: Jan 16, 2025
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) to assess compliance with Life Safety from Fire and related regulations.
Findings
The facility was found not in compliance with several Life Safety Code requirements including hazardous area enclosures, sprinkler system maintenance, fire door operation, use of portable space heaters, emergency generator testing documentation, and improper use of extension cords and multiplug adapters. Corrective actions were implemented with ongoing monitoring.
Deficiencies (6)
Failed to ensure hazardous areas such as fuel-fired heater rooms were separated by smoke resistant partitions and doors.
Failed to maintain ceiling construction around sprinkler heads in kitchen according to NFPA 13.
Failed to ensure proper operation of rolling steel fire doors with automatic closing devices.
Use of portable space heaters in the facility where prohibited.
Failed to document emergency generator monthly load testing for 3 months and failed to document 5 minute cool down period for 6 months.
Failed to ensure multiplug adapters and extension cords were not used as substitutes for fixed wiring.
Report Facts
Certified beds: 136
Census: 74
Deficiencies cited: 6
Emergency generator load test duration: 5
Emergency generator cool down time: 2
Fire resistance rating: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Aldridge | Executive Director | Reviewed findings during exit conference |
| Director of Maintenance | Interviewed and involved in observations and corrective actions for multiple deficiencies |
Inspection Report
Renewal
Census: 74
Capacity: 74
Deficiencies: 3
Date: Dec 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00449216.
Complaint Details
Complaint IN00449216 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in medication administration for one resident related to dialysis, food safety and hygiene practices in the kitchen, and environmental safety issues including non-functional call lights and missing cove base in resident bathrooms. No deficiencies were related to the complaint investigation.
Deficiencies (3)
Failed to ensure a medication was administered as ordered for 1 of 1 resident reviewed for dialysis (Resident 71).
Failed to label refrigerated food with date opened, appropriately store frozen food, restrain facial hair of dietary staff, and store personal belongings away from drying rack of clean dishes, potentially affecting 67 of 74 residents.
Failed to have a functional call light in a resident's room and timely replace cove base at the base of a toilet for 2 of 7 residents observed for environment (Residents 13 and 48).
Report Facts
Census: 74
Total Capacity: 74
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Coomer | RN | Signed as Laboratory Director or Provider/Supplier Representative. |
| Director of Nursing | Interviewed regarding medication administration and policies. | |
| Dietary Manager | Interviewed regarding food safety and hygiene deficiencies. | |
| Maintenance Supervisor | Interviewed regarding environmental deficiencies related to cove base replacement. | |
| Vice President of Risk and Regulatory | Interviewed regarding call light policy and standards of care. | |
| Executive Director | Provided Facility Maintenance Guidelines and Procedures. | |
| Certified Nurse Aide 1 | Interviewed regarding broken call light for Resident 48. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 20, 2024
Visit Reason
The inspection was a paper compliance review related to the Annual Recertification and State Licensure survey.
Findings
Brickyard Healthcare - Brookview Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the paper compliance review for the Annual Recertification and State Licensure survey.
Inspection Report
Routine
Deficiencies: 3
Date: Dec 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to medication administration, food safety, and environmental safety within the nursing home.
Findings
The facility failed to ensure proper medication administration for one resident on dialysis, maintain food safety standards including proper labeling and storage, and ensure environmental safety by having functional call lights and timely maintenance in resident rooms.
Deficiencies (3)
Failed to ensure a medication was administered as ordered for 1 of 1 resident reviewed for dialysis (Resident 71).
Failed to label refrigerated food with date opened, appropriately store frozen food, restrain facial hair of dietary staff with beard restraint, and store personal belongings away from drying rack of clean dishes, potentially affecting 67 of 74 residents.
Failed to have a functional call light in a resident's room and timely replace cove base at the base of a toilet for 2 of 7 residents observed for environment (Residents 13 and 48).
Report Facts
Residents affected: 1
Residents affected: 67
Total residents in facility: 74
Residents affected: 2
Residents observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication administration error | |
| Dietary Manager | Interviewed and observed during food safety inspection | |
| Maintenance Supervisor | Interviewed regarding environmental maintenance issues | |
| Certified Nurse Aide 1 | Interviewed regarding broken call light | |
| President of Risk and Regulatory | Interviewed regarding call light policy | |
| Executive Director | Provided facility maintenance guidelines |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Oct 28, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00444550, IN00444849, IN00444876, IN00444882, and IN00446042.
Complaint Details
Complaints IN00444550, IN00444849, IN00444876, IN00444882, and IN00446042 were investigated and no deficiencies related to the allegations were found.
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.
Report Facts
Census Bed Type: 77
Total Capacity: 77
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 54
Census Payor Type - Other: 22
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00442213 completed on September 20, 2024.
Complaint Details
Complaint IN00442213 was investigated with a paper compliance review, and the facility was found to be in compliance.
Findings
Brickyard Healthcare - Brookview 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.
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 3
Date: Sep 20, 2024
Visit Reason
This visit was for the investigation of Complaint IN00442213, which involved federal and state deficiencies related to allegations of abuse and failure to investigate abuse properly.
Complaint Details
Complaint IN00442213 involved allegations of abuse and failure to investigate abuse properly. The complaint was substantiated with deficiencies cited at F550 and F610 related to resident rights and abuse investigation.
Findings
The facility was found to have failed to ensure a resident's right to be treated with respect and dignity, failed to thoroughly investigate an allegation of abuse, and failed to identify individualized behavioral health approaches for a resident with dementia and agitation. Multiple deficiencies related to resident rights, abuse investigation, and behavioral health services were cited.
Deficiencies (3)
Failed to ensure a resident's right to be treated with respect and dignity by a staff member who forcefully attempted to get a resident to perform her own incontinent care.
Failed to thoroughly investigate an allegation of abuse for a resident, including missing witness and victim statements.
Failed to identify individualized approaches of care for a resident with dementia with agitation and to prevent the resident's distress.
Report Facts
Census: 77
Total Capacity: 77
Medicare Census: 4
Medicaid Census: 53
Other Payor Census: 20
Deficiency Completion Date: Oct 11, 2024
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 20, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging abuse and failure to properly investigate the abuse at Brickyard Healthcare - Brookview Care Center.
Complaint Details
The citation is related to Complaint IN00442213. The complaint involved allegations of abuse to Resident D and failure to properly investigate the incident. The investigation lacked statements from key witnesses including the physician's assistant and the reporting CNA. Resident D reported feeling upset, degraded, and humiliated by the nurse's forceful actions.
Findings
The facility failed to ensure a resident's right to be treated with respect and dignity, failed to thoroughly investigate an allegation of abuse, and failed to provide necessary individualized behavioral health care for residents with dementia and agitation. Specific incidents involved forceful assistance with incontinent care and aggressive behaviors not properly addressed in care plans.
Deficiencies (3)
Failed to ensure a resident's right to be treated with respect and dignity by a staff member who forcefully attempted to get a resident to perform her own incontinent care.
Failed to thoroughly investigate an allegation of abuse, including missing witness statements and incomplete documentation.
Failed to identify individualized approaches of care for a resident with dementia and agitation and to prevent resident distress.
Report Facts
Residents reviewed for abuse: 3
Dates of key events: Aug 20, 2024
Dates of physician orders: 2024-07-18 to 2024-08-23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident D | Resident | Subject of abuse allegation and interviewee describing the incident. |
| Executive Director | Executive Director (ED) | Interviewed regarding the abuse incident and investigation. |
| QMA 3 | Qualified Medication Assistant 3 | Witness to aggressive behavior incident involving Resident C. |
| Director of Nursing Services | Director of Nursing Services (DNS) | Interviewed regarding Resident C's care and behavioral health services. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00440636, IN00440288, and IN00437605.
Complaint Details
Complaints IN00440636, IN00440288, and IN00437605 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the complaint investigations.
Report Facts
Census: 73
Total Capacity: 73
Medicare Census: 2
Medicaid Census: 50
Other Payor Census: 21
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
Paper compliance review to the Complaint Investigation completed on June 4, 2024.
Complaint Details
The visit was related to a complaint investigation with paper compliance review completed on June 4, 2024. The facility was found to be in compliance.
Findings
Brickyard Healthcare - Brookview 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 to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 1
Date: Jun 4, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431214, IN00431637, IN00434590, and IN00434674 at Brickyard Healthcare - Brookview Care Center.
Complaint Details
Complaints IN00431214, IN00431637, IN00434590, and IN00434674 were investigated. No deficiencies related to the allegations in these complaints were cited.
Findings
No deficiencies related to the complaints were cited. However, unrelated deficiencies were identified, including a failure to ensure follow-up for a resident who was unaccounted for during the night, indicating inadequate supervision and follow-up on therapeutic leave.
Deficiencies (1)
Failed to ensure follow-up to a resident that was unable to be located in the facility during the night for 1 of 4 residents reviewed for accidents (Resident B).
Report Facts
Census: 75
Total Capacity: 75
Medicare Residents: 5
Medicaid Residents: 50
Other Payor Residents: 20
Therapeutic leave absence days: 9
Audit frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Expressed concern about Resident B's whereabouts and medication safety |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 4, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure follow-up for a resident (Resident B) who was unable to be located during the night.
Complaint Details
The complaint investigation found that Resident B left the facility without signing out or notifying staff, and staff were unaware of his whereabouts or medication status. The receptionist saw Resident B leave but did not inform staff. The Director of Nursing expressed concern about the situation. The facility's therapeutic leave policy was reviewed and found to require better adherence.
Findings
The facility failed to ensure proper supervision and follow-up for Resident B who left the facility without signing out or notifying staff, resulting in staff being unaware of his whereabouts, medication status, and safety during his absence. The receptionist also failed to notify staff when Resident B left, and the facility's policy on therapeutic leave was not properly followed.
Deficiencies (1)
Failed to ensure follow up to a resident that was unable to be located in the facility during the night for 1 of 4 residents reviewed for accidents.
Report Facts
Residents reviewed for accidents: 4
Leave of absence days in March: 9
Leave of absence days in April: 7
Leave of absence days in May: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Expressed concern about Resident B's whereabouts and medication status during the investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
The visit was conducted to investigate multiple complaints identified as IN00424987, IN00428474, IN00428569, IN00428773, and IN00429205.
Complaint Details
Complaints IN00424987, IN00428474, IN00428569, IN00428773, and IN00429205 were investigated and found to have no deficiencies related to the allegations.
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.
Report Facts
Census SNF/NF: 65
Total Capacity: 65
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 50
Census Payor Type Other: 13
Inspection Report
Life Safety
Census: 63
Capacity: 136
Deficiencies: 0
Date: Feb 16, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/21/23 & 12/22/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
Brickyard Healthcare-Brookview Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 136
Census: 63
Inspection Report
Life Safety
Census: 65
Capacity: 136
Deficiencies: 10
Date: Dec 22, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 12/21/23 and 12/22/23 to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to delayed egress door signage, means of egress accessibility, egress lighting, kitchen exhaust system inspection, sprinkler system maintenance, portable fire extinguisher inspections, fire drills documentation, fire door inspections, and use of power strips in patient care areas.
Deficiencies (10)
Failed to ensure means of egress through 1 of 6 delayed egress locks were readily accessible and lacked required signage.
Failed to ensure means of egress through 1 of 9 exits were readily accessible; exit door code not posted.
Failed to ensure continuity of egress lighting for 1 of 9 exits; exit discharge near Room 302 lacked egress lighting.
Failed to ensure egress lighting arranged so failure of any single lighting fixture would not leave area in darkness; one bulb burnt out near Room 200 exit.
Failed to ensure kitchen exhaust system was inspected semiannually as required by NFPA 96.
Failed to maintain ceiling construction for 1 of 2 ceilings affecting sprinkler operation due to gaps in attic access doors.
Failed to ensure 2 of 21 portable fire extinguishers were inspected monthly and inspections documented.
Failed to provide documentation of a fire drill conducted on the second shift for 1 of 4 quarters.
Failed to ensure annual inspection and testing of all fire door assemblies were completed and documented.
Failed to ensure extension cords including power strips were not used as a substitute for fixed wiring in patient care vicinity.
Report Facts
Certified beds: 136
Census: 65
Fire extinguishers inspected monthly: 2
Fire drills missing documentation: 1
Oxygen containers: 11
Oxygen cylinders: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keary Dye | Transitional ED | Signed laboratory director/provider/supplier representative signature on report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423343.
Complaint Details
Complaint IN00423343 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 3
Medicaid census: 33
Other census: 29
Inspection Report
Annual Inspection
Census: 69
Capacity: 69
Deficiencies: 5
Date: Nov 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00418192.
Complaint Details
Complaint IN00418192 was investigated during this visit. Federal/State deficiencies related to the allegations were cited at F550 (Resident Rights/Exercise of Rights) and F585 (Grievances).
Findings
The facility was found deficient in maintaining residents' dignity and respect, timely addressing grievances, care plan participation, catheter care, and dementia care activities and interventions. Specific issues included staff disrespect to residents, incomplete grievance documentation, lack of care plan follow-up with representatives, improper catheter care, and inadequate activity programming for memory care residents.
Deficiencies (5)
Facility failed to ensure residents' dignity was maintained by staff not being respectful for 6 of 69 residents reviewed.
Facility failed to ensure residents' grievances were addressed timely and grievance forms completed for 1 of 1 resident reviewed for missing property and 1 of 3 residents reviewed for dignity.
Facility failed to follow up with a resident's representative regarding care plan meeting for 1 of 1 resident reviewed for care planning.
Facility failed to ensure a resident's catheter was flushed as ordered; catheter tubing not touching the ground or kinked; and good hygiene practices during catheter care for 1 of 1 residents reviewed for catheter.
Facility failed to provide residents on the memory care unit with a consistent activity program that considered their cognitive status; update a resident's dementia care plan to include specific interventions for behaviors; attempt non-pharmacological interventions prior to increasing psychotropic medication; and timely update the plan of care for residents with wandering behaviors.
Report Facts
Census: 69
Total Capacity: 69
Residents reviewed for dignity: 6
Residents on memory care unit: 24
Residents with wandering behaviors reviewed: 24
Residents reviewed for dementia care: 3
Residents with catheters audited weekly: 3
Residents with catheter care observed weekly: 2
Residents audited weekly for dignity/respect: 5
Residents audited weekly for dignity/respect follow-up: 3
Residents audited weekly for grievances: 5
Residents audited weekly for grievances follow-up: 3
Care plan meeting follow-up period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Coomer | RN-DNS | Named as Laboratory Director or Provider/Supplier Representative on report |
| LPN 10 | Licensed Practical Nurse | Named in resident dignity complaint for rude behavior |
| Administrator In Training | AIT | Interviewed regarding resident dignity and grievance issues |
| Director of Nursing | DON | Interviewed regarding dignity, grievance, catheter care, and dementia care policies |
| Executive Director | ED | Interviewed regarding staff morale and facility efforts |
| QMA 4 | Qualified Medication Aide | Provided care and interventions for residents with dementia and behaviors |
| CNA 13 | Certified Nursing Assistant | Interviewed regarding dementia care and resident behaviors |
| LPN 7 | Licensed Practical Nurse | Observed providing catheter care |
| Memory Care Director | MCD | Interviewed regarding memory care activities and resident behaviors |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
Paper compliance review to the Recertification, State Licensure, and Investigation of Complaint IN00418192.
Findings
Golden Living Center Brookview 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 for Recertification, State Licensure, and Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 17, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00418192) regarding staff disrespect and failure to maintain residents' dignity.
Complaint Details
This citation relates to complaint IN00418192. The complaint involved reports of staff rudeness, disrespectful behavior, and use of vulgar language within earshot of residents.
Findings
The facility failed to ensure residents' dignity was maintained, with staff being disrespectful to 6 of 69 residents reviewed. Interviews revealed rude behavior by staff, including yelling, disrespectful comments, and unprofessional language heard by residents and family members.
Deficiencies (1)
Failure to ensure residents' dignity was maintained by staff not being respectful for 6 of 69 residents reviewed.
Report Facts
Residents reviewed for dignity: 69
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 10 | Licensed Practical Nurse | Named in findings related to rude behavior and disrespect towards residents B and C |
| Director of Nursing | Director of Nursing (DON) | Provided policies and interviewed regarding staff education and morale |
| Executive Director | Executive Director (ED) | Interviewed regarding staff morale and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 17, 2023
Visit Reason
The inspection was conducted in response to complaint IN00418192 regarding resident dignity, grievances, care planning, catheter care, and dementia care on the memory care unit.
Complaint Details
The citation relates to complaint IN00418192 involving issues of resident dignity, grievance handling, care planning, catheter care, and dementia care.
Findings
The facility was found deficient in maintaining resident dignity with staff disrespectful behavior towards some residents, failure to timely address grievances, incomplete care planning communication with a resident's representative, inadequate catheter care, and insufficient dementia care programming and interventions for residents on the memory care unit.
Deficiencies (5)
Failure to ensure residents' dignity was maintained by staff not being respectful for 6 of 69 residents reviewed.
Failure to ensure residents' grievances were addressed and timely completed for 1 of 1 resident reviewed for missing property and 1 of 3 residents reviewed for dignity.
Failure to follow up with a resident's representative regarding their care plan meeting for 1 of 1 resident reviewed for care planning.
Failure to provide appropriate catheter care including flushing as ordered and preventing catheter tubing from touching the ground or being kinked for 1 of 1 residents reviewed for catheter care.
Failure to provide residents on the memory care unit with a consistent activity program that considered their cognitive status; failure to update a resident's dementia care plan to include specific interventions for crying out during group settings; failure to attempt non-pharmacological interventions prior to increasing psychotropic medication; and failure to timely update the plan of care for a resident with wandering behaviors for 2 of 3 residents reviewed for dementia care and 24 of 24 residents on the memory care unit.
Report Facts
Residents reviewed for dignity: 69
Residents affected by dignity deficiency: 6
Residents reviewed for grievance: 3
Residents reviewed for care planning: 1
Residents reviewed for catheter care: 1
Residents reviewed for dementia care: 3
Residents on memory care unit: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 10 | Licensed Practical Nurse | Named in resident dignity and grievance complaints for rude behavior |
| Administrator In Training | Administrator In Training (AIT) | Interviewed regarding resident complaints and observed conducting trivia activity |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff morale, policies, and care planning |
| LPN 7 | Licensed Practical Nurse | Observed providing catheter care and reported medication unavailability |
| QMA 4 | Qualified Medication Aide | Interviewed regarding dementia care and resident behaviors |
| CNA 13 | Certified Nursing Assistant | Interviewed regarding dementia care and resident behaviors |
| Memory Care Director | Memory Care Director (MCD) | Interviewed regarding dementia care programming and resident behaviors |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416846.
Complaint Details
Complaint IN00416846 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B regarding the complaint investigation.
Report Facts
Census bed type: 67
Census payor type - Medicare: 3
Census payor type - Medicaid: 30
Census payor type - Other: 34
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415067.
Complaint Details
Complaint IN00415067 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00415067 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 8
Medicaid census: 38
Other payor census: 18
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Date: Jul 18, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00413009.
Complaint Details
Complaint IN00413009 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the complaint investigation.
Report Facts
Census: 63
Total Capacity: 63
Medicare Census: 2
Medicaid Census: 31
Other Payor Census: 30
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403488 and IN00405669.
Complaint Details
Investigation of Complaints IN00403488 and IN00405669 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00403488 and IN00405669 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 66
Total Capacity: 66
Medicare Census: 2
Medicaid Census: 39
Other Payor Census: 25
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Jan 31, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00399181 and IN00399779.
Complaint Details
Complaint IN00399181 - Substantiated with no deficiencies cited. Complaint IN00399779 - Substantiated with no deficiencies cited.
Findings
Both complaints IN00399181 and IN00399779 were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 6
Medicaid census: 47
Other payor census: 23
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 6, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00392569 and IN0096362 completed on December 9, 2022.
Complaint Details
The visit was related to complaint investigations IN00392569 and IN0096362; compliance was found.
Findings
Golden Living Center Brookview 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 to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398155.
Complaint Details
Complaint IN00398155 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint IN00398155 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 75
Total Capacity: 75
Medicare Census: 3
Medicaid Census: 52
Other Payor Census: 20
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 2
Date: Dec 9, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00392569 and IN00396362. Complaint IN00392569 was unsubstantiated due to lack of evidence, while Complaint IN00396362 was substantiated with related federal and state deficiencies cited.
Complaint Details
Complaint IN00392569 was unsubstantiated due to lack of evidence. Complaint IN00396362 was substantiated with federal and state deficiencies cited at F-600 and F-9999.
Findings
The facility failed to prevent verbal abuse and provide psychosocial support to a resident (Resident G) after a nurse verbally abused her. Additionally, the facility failed to ensure that reference checks were completed for 6 of 7 employees reviewed.
Deficiencies (2)
Failure to prevent verbal abuse and provide psychosocial support to a resident after a nurse yelled, cursed, and argued with the resident and took the resident's items away.
Failure to ensure reference checks were completed for 6 of 7 employees reviewed upon hire.
Report Facts
Census: 76
Total Capacity: 76
Medicare Census: 6
Medicaid Census: 49
Other Payor Census: 21
Employees without reference checks: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justin P. Vogt | Executive Director | Signed report as facility representative |
| LPN 1 | Named in verbal abuse incident with Resident G | |
| LPN 2 | Named in reference check deficiency and verbal abuse investigation | |
| CNA 3 | Named in reference check deficiency | |
| CNA 4 | Named in verbal abuse investigation and reference check deficiency | |
| CNA 5 | Named in reference check deficiency | |
| CNA 6 | Named in reference check deficiency |
Inspection Report
Re-Inspection
Census: 74
Capacity: 136
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
A Post Survey Revisit (PSR) to the PSR survey conducted on 10/07/22 to the Life Safety Code Recertification and State Licensure Survey conducted on 08/10/22 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Brickyard Healthcare-Brookview 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for one detached shed providing facility storage services which was not sprinklered.
Report Facts
Facility capacity: 136
Census: 74
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Oct 17, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00391416 and IN00390330.
Complaint Details
Complaint IN00391416 - Substantiated with no deficiencies cited. Complaint IN00390330 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00391416 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00390330 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 80
Total Census: 80
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 51
Census Payor Type - Other: 25
Inspection Report
Re-Inspection
Census: 79
Capacity: 136
Deficiencies: 2
Date: Oct 7, 2022
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted to verify compliance and correction of previously cited deficiencies.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, deficiencies were found related to Life Safety Code including failure to maintain means of egress free from obstructions and failure to maintain smoke barrier fire resistance rating due to unprotected penetrations. Plans of correction were submitted and corrective actions were underway.
Deficiencies (2)
Failed to maintain the means of egress free from obstructions in 1 of 9 means of egress; the west door nearest the emergency generator was stuck on the threshold and would not release to open.
Failed to ensure openings through 1 of 2 ceiling smoke barriers was protected to maintain the fire resistance rating; a three inch hole in the ceiling of the main Mechanical Room was not protected.
Report Facts
Certified beds: 136
Census: 79
Means of egress affected: 1
Diameter of hole: 3
Diameter of conduit: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Participated in observations and interviews related to means of egress obstruction and smoke barrier deficiencies | |
| Maintenance Director | Participated in observations and interviews related to means of egress obstruction and smoke barrier deficiencies; responsible for audits and corrective actions |
Inspection Report
Re-Inspection
Census: 80
Capacity: 80
Deficiencies: 0
Date: Aug 15, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on July 13, 2022.
Findings
Brickyard Healthcare-Brookview 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 Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 46
Census Payor Type - Other: 26
Inspection Report
Life Safety
Census: 82
Capacity: 136
Deficiencies: 13
Date: Aug 10, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness training requirements, emergency power system testing, means of egress obstructions, kitchen range hood maintenance, sprinkler system installation, portable fire extinguisher inspections, corridor door smoke resistance, smoke barrier penetrations, fire drills documentation, fire door inspections, and use of extension cords as substitutes for fixed wiring.
Deficiencies (13)
Failed to ensure emergency preparedness training and testing program included required training and documentation.
Failed to implement emergency power system inspection, testing and maintenance requirements including missing monthly load testing documentation for two months.
Failed to maintain means of egress free from obstructions due to a slide bolt locking an exit door.
Failed to ensure repair documentation was available for kitchen range hood exhaust system deficiencies.
Failed to maintain kitchen range hood drip tray with an enclosed metal container for grease collection.
Failed to maintain sprinkler escutcheon flush with ceiling in a resident room closet.
Failed to ensure portable fire extinguishers were inspected monthly and documented properly.
Failed to ensure corridor door resisted passage of smoke due to holes in door.
Failed to protect penetrations through ceiling smoke barriers to maintain fire resistance rating.
Failed to adequately document quarterly fire drills on all shifts.
Failed to ensure annual inspection and testing of all fire door assemblies were completed and properly documented.
Failed to document emergency generator monthly load testing for two months of the most recent 12 month period.
Failed to ensure extension cords were not used as a substitute for fixed wiring; observed spooled extension cord in use.
Report Facts
Certified beds: 136
Census: 82
Fire door locations inspected: 11
Fire door locations identified: 12
Fire extinguishers with missing monthly inspections: 4
Fire drills missing documentation: 4
Months missing emergency generator load testing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding emergency preparedness training, emergency power testing, and other findings | |
| Visiting Maintenance Director | Interviewed and observed during facility tour regarding multiple life safety deficiencies | |
| Maintenance Director in training | Observed during facility tour regarding multiple life safety deficiencies |
Inspection Report
Routine
Deficiencies: 19
Date: Jul 13, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, environment, abuse reporting, personal property, care planning, skin and wound care, activities of daily living, nutrition, pain management, dialysis care, pharmaceutical services, dental services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, provide safe and comfortable environment, timely report abuse, complete personal property inventories, involve residents in care planning, provide appropriate wound care, assist with activities of daily living, provide adequate nutrition and supplements, manage pain effectively, monitor dialysis access, ensure timely medication availability, provide dental services, and maintain infection control practices including signage and PPE use.
Deficiencies (19)
Failed to ensure a resident's dignity was maintained by not removing hospital bands for 1 of 3 residents reviewed for dignity (Resident 50).
Failed to provide a resident with a wheelchair in good repair for 1 of 2 residents reviewed for environment (Resident 19).
Failed to timely address a malfunctioning bathroom door for 1 of 2 residents reviewed for environment (Resident 35).
Failed to immediately report an allegation of abuse to the Administrator for 2 of 4 residents reviewed for abuse (Residents 19 and 44).
Failed to timely complete an inventory of a resident's personal belongings for 1 of 1 resident reviewed for personal property (Resident 80).
Failed to ensure a resident and/or representative was informed and provided a written copy of the developed baseline care plan for 1 of 2 residents reviewed for baseline care plan (Resident 185).
Failed to invite residents to participate in their care plan meetings for 4 of 6 residents reviewed for care plan participation (Residents 35, 54, 69, 80).
Failed to assure that a wound dressing was completed by a licensed nurse for 1 of 3 residents reviewed for skin conditions (Resident 80).
Failed to provide bathing, shaving and nail care as necessary to 6 of 9 residents reviewed for activities of daily living (Residents 19, 54, 69, 72, 80, and 132).
Failed to perform a wound dressing, as ordered by the physician, for 1 of 3 residents reviewed for skin conditions (Resident 80).
Failed to address a resident's hearing difficulty and follow up with a resident after a vision consult for 2 of 3 residents reviewed for communication and sensory (Residents 19 and 50).
Failed to provide nutritional supplements and food, as preferred, for 1 of 2 residents reviewed for nutrition (Resident 9).
Failed to adequately monitor and manage a resident's hand pain for 1 of 2 residents reviewed for pain (Resident 54).
Failed to monitor and document assessment of a resident's dialysis access site for 1 of 1 resident reviewed for dialysis (Resident 54).
Failed to ensure a new admitted resident's medications were available timely for 1 of 6 residents reviewed for unnecessary medications (Resident 185).
Failed to provide routine dental services and emergency dental services for a resident who experienced pain with chewing for 2 of 6 residents reviewed for dental status and services (Residents 26 and 69).
Failed to provide dental services to 2 of 6 residents reviewed for dental status and services (Residents 45 and 54).
Failed to maintain infection control practices during a COVID-19 pandemic by failing to assure signage was posted on the 2 residents doors indicating they were in droplet plus transmission based precautions and to assure that disposable gloves were worn during administration of a nasal spray for 2 of 2 residents reviewed for transmission based precautions and 1 resident randomly observed during medication pass (Residents 40, 79 and 18).
Failed to timely address a pest control issue of ants in memory care unit dining room with the potential to affect 21 of 79 residents residing at the facility.
Report Facts
Deficiencies cited: 18
Residents affected by pest control issue: 21
Residents in facility: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 11 | Certified Nursing Assistant | Mentioned in relation to hospital band removal deficiency for Resident 50 |
| License Practical Nurse 12 | Licensed Practical Nurse | Interviewed regarding hospital band removal for Resident 50 |
| Acting Maintenance Director | Maintenance Director | Interviewed regarding wheelchair repair and bathroom door issues |
| Executive Director | Executive Director | Interviewed regarding abuse reporting, pest control, and other deficiencies |
| Director of Nursing | Director of Nursing | Provided policies and interviewed regarding dignity, wound care, infection control, and other deficiencies |
| Nurse Consultant | Nurse Consultant | Interviewed regarding abuse reporting, care plan participation, hearing difficulty, and wound care |
| Qualified Medication Aide 6 | Qualified Medication Aide | Mentioned in relation to wound care and medication administration |
| Qualified Medication Aide 8 | Qualified Medication Aide | Mentioned in relation to wound care and medication administration |
| Resident 19 | Resident | Subject of wheelchair repair, abuse incident, hearing difficulty, and bathing deficiencies |
| Resident 44 | Resident | Subject of abuse incident and reporting deficiency |
| Resident 50 | Resident | Subject of dignity, hearing, and vision services deficiencies |
| Resident 54 | Resident | Subject of care plan participation, pain management, dialysis care, dental services, and bathing deficiencies |
| Resident 69 | Resident | Subject of care plan participation, dental services, and bathing deficiencies |
| Resident 80 | Resident | Subject of personal property inventory, wound care, shaving, and bathing deficiencies |
| Resident 132 | Resident | Subject of nail care deficiency |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding pain management and dialysis care for Resident 54 |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding dialysis care for Resident 54 |
| LPN 22 | Licensed Practical Nurse | Observed administering nasal spray without gloves |
| Nurse Practitioner 4 | Nurse Practitioner | Interviewed regarding pain management for Resident 54 |
| Social Services Director | Social Services Director | Interviewed regarding dental services and hearing/vision services |
| Guardian 15 | Guardian | Interviewed regarding dental services for Resident 45 |
| Certified Nursing Assistant 14 | Certified Nursing Assistant | Mentioned in relation to nail care for Resident 72 |
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