Inspection Reports for Brickyard Healthcare – Brookview Care Center
7145 E 21ST STREET, IN, 46219
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
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.
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.
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.
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
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.
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.
Complaint Details
This visit was related to the investigation of Complaint IN00459452 and other complaints. Complaint IN00459452 was corrected as of this visit.
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
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.
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.
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.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident was transported to appointments regarding a tunneled catheter removal. | SS=D |
| Failure to ensure a resident with intravenous (IV) access had orders for continued care of the IV access. | SS=D |
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: 0
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.
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.
Complaint Details
Complaint IN00454054 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Mar 14, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454878.
Findings
No deficiencies related to the allegations in Complaint IN00454878 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00454878 found no deficiencies related to the allegations.
Report Facts
Medicare census: 4
Medicaid census: 54
Other payor census: 21
Inspection Report
Re-Inspection
Census: 82
Capacity: 136
Deficiencies: 0
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
Census: 79
Capacity: 79
Deficiencies: 2
Mar 3, 2025
Visit Reason
The visit was conducted for the investigation of two complaints, IN00453279 and IN00454054, regarding resident care and facility practices.
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.
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.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident's call light was responded to in a timely manner, resulting in resident anxiety. | SS=D |
| Failure to provide a resident with a copy of the facility's bed hold policy prior to transferring to an area hospital. | SS=D |
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
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.
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.
Complaint Details
Complaint IN00451414 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 2
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.
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.
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.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate an allegation of misappropriation of property for Resident D. | SS=D |
| Failed to ensure narcotic pain medication was placed in a controlled substance lock box and properly documented during shift audits for Resident E. | SS=D |
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
Life Safety
Census: 74
Capacity: 136
Deficiencies: 6
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.
Severity Breakdown
SS=F: 2
SS=E: 3
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure hazardous areas such as fuel-fired heater rooms were separated by smoke resistant partitions and doors. | SS=F |
| Failed to maintain ceiling construction around sprinkler heads in kitchen according to NFPA 13. | SS=D |
| Failed to ensure proper operation of rolling steel fire doors with automatic closing devices. | SS=E |
| Use of portable space heaters in the facility where prohibited. | SS=E |
| Failed to document emergency generator monthly load testing for 3 months and failed to document 5 minute cool down period for 6 months. | SS=F |
| Failed to ensure multiplug adapters and extension cords were not used as substitutes for fixed wiring. | SS=E |
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
Dec 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00449216.
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.
Complaint Details
Complaint IN00449216 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a medication was administered as ordered for 1 of 1 resident reviewed for dialysis (Resident 71). | SS=D |
| 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. | SS=E |
| 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). | SS=D |
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
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
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Oct 28, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00444550, IN00444849, IN00444876, IN00444882, and IN00446042.
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.
Complaint Details
Complaints IN00444550, IN00444849, IN00444876, IN00444882, and IN00446042 were investigated and no deficiencies related to the allegations were found.
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
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.
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.
Complaint Details
Complaint IN00442213 was investigated with a paper compliance review, and the facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 3
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.
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.
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.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| 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. | SS=D |
| Failed to thoroughly investigate an allegation of abuse for a resident, including missing witness and victim statements. | SS=D |
| Failed to identify individualized approaches of care for a resident with dementia with agitation and to prevent the resident's distress. | SS=D |
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
Census: 73
Capacity: 73
Deficiencies: 0
Aug 13, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00440636, IN00440288, and IN00437605.
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.
Complaint Details
Complaints IN00440636, IN00440288, and IN00437605 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 73
Total Capacity: 73
Medicare Census: 2
Medicaid Census: 50
Other Payor Census: 21
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 1, 2024
Visit Reason
Paper compliance review to the Complaint Investigation completed on June 4, 2024.
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.
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.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 1
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.
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.
Complaint Details
Complaints IN00431214, IN00431637, IN00434590, and IN00434674 were investigated. No deficiencies related to the allegations in these complaints were cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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). | SS=D |
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
Census: 65
Capacity: 65
Deficiencies: 0
Mar 14, 2024
Visit Reason
The visit was conducted to investigate multiple complaints identified as IN00424987, IN00428474, IN00428569, IN00428773, and IN00429205.
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.
Complaint Details
Complaints IN00424987, IN00428474, IN00428569, IN00428773, and IN00429205 were investigated and found to have no deficiencies related to the allegations.
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
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
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.
Severity Breakdown
SS=E: 7
SS=D: 1
SS=F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure means of egress through 1 of 6 delayed egress locks were readily accessible and lacked required signage. | SS=E |
| Failed to ensure means of egress through 1 of 9 exits were readily accessible; exit door code not posted. | SS=E |
| Failed to ensure continuity of egress lighting for 1 of 9 exits; exit discharge near Room 302 lacked egress lighting. | SS=E |
| 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. | SS=E |
| Failed to ensure kitchen exhaust system was inspected semiannually as required by NFPA 96. | SS=D |
| Failed to maintain ceiling construction for 1 of 2 ceilings affecting sprinkler operation due to gaps in attic access doors. | SS=E |
| Failed to ensure 2 of 21 portable fire extinguishers were inspected monthly and inspections documented. | SS=E |
| Failed to provide documentation of a fire drill conducted on the second shift for 1 of 4 quarters. | SS=F |
| Failed to ensure annual inspection and testing of all fire door assemblies were completed and documented. | SS=F |
| Failed to ensure extension cords including power strips were not used as a substitute for fixed wiring in patient care vicinity. | SS=E |
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
Dec 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423343.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00423343 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 3
Medicaid census: 33
Other census: 29
Inspection Report
Annual Inspection
Census: 69
Capacity: 69
Deficiencies: 5
Nov 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00418192.
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.
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).
Severity Breakdown
SS=E: 2
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure residents' dignity was maintained by staff not being respectful for 6 of 69 residents reviewed. | SS=E |
| 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. | SS=D |
| Facility failed to follow up with a resident's representative regarding care plan meeting for 1 of 1 resident reviewed for care planning. | SS=D |
| 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. | SS=D |
| 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. | SS=E |
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
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
Census: 67
Capacity: 67
Deficiencies: 0
Sep 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416846.
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.
Complaint Details
Complaint IN00416846 was investigated and found to have no deficiencies related to the allegations.
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
Aug 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415067.
Findings
No deficiencies related to the allegations in Complaint IN00415067 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00415067 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 8
Medicaid census: 38
Other payor census: 18
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Jul 18, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00413009.
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.
Complaint Details
Complaint IN00413009 - No deficiencies related to the allegations are cited.
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
Apr 12, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403488 and IN00405669.
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.
Complaint Details
Investigation of Complaints IN00403488 and IN00405669 found no deficiencies related to the allegations.
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
Jan 31, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00399181 and IN00399779.
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.
Complaint Details
Complaint IN00399181 - Substantiated with no deficiencies cited. Complaint IN00399779 - Substantiated with no deficiencies cited.
Report Facts
Medicare census: 6
Medicaid census: 47
Other payor census: 23
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 6, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00392569 and IN0096362 completed on December 9, 2022.
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.
Complaint Details
The visit was related to complaint investigations IN00392569 and IN0096362; compliance was found.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Jan 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398155.
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.
Complaint Details
Complaint IN00398155 was substantiated but no deficiencies related to the allegations were cited.
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
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.
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.
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.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| 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. | SS=D |
| 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
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
Oct 17, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00391416 and IN00390330.
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.
Complaint Details
Complaint IN00391416 - Substantiated with no deficiencies cited. Complaint IN00390330 - Unsubstantiated due to lack of evidence.
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
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.
Severity Breakdown
SS=E: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| 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. | SS=E |
| 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. | SS=F |
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
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
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.
Severity Breakdown
SS=F: 6
SS=E: 5
SS=D: 2
SS=C: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness training and testing program included required training and documentation. | SS=F |
| Failed to implement emergency power system inspection, testing and maintenance requirements including missing monthly load testing documentation for two months. | SS=F |
| Failed to maintain means of egress free from obstructions due to a slide bolt locking an exit door. | SS=E |
| Failed to ensure repair documentation was available for kitchen range hood exhaust system deficiencies. | SS=D |
| Failed to maintain kitchen range hood drip tray with an enclosed metal container for grease collection. | SS=D |
| Failed to maintain sprinkler escutcheon flush with ceiling in a resident room closet. | SS=E |
| Failed to ensure portable fire extinguishers were inspected monthly and documented properly. | SS=E |
| Failed to ensure corridor door resisted passage of smoke due to holes in door. | SS=E |
| Failed to protect penetrations through ceiling smoke barriers to maintain fire resistance rating. | SS=F |
| Failed to adequately document quarterly fire drills on all shifts. | SS=C |
| Failed to ensure annual inspection and testing of all fire door assemblies were completed and properly documented. | SS=F |
| Failed to document emergency generator monthly load testing for two months of the most recent 12 month period. | SS=F |
| Failed to ensure extension cords were not used as a substitute for fixed wiring; observed spooled extension cord in use. | SS=E |
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 |
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