Inspection Reports for Brickyard Healthcare – Muncie Care Center
2701 LYN-MAR DR, IN, 47304
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 20, 2025, found the facility in compliance with no deficiencies noted. Prior inspections showed a pattern of deficiencies related mainly to resident care issues, including medication management, catheter care, and infection control, as well as life safety code violations such as exit door accessibility and corridor obstructions. Several complaint investigations substantiated deficiencies involving medication administration errors, failure to prevent abuse, and inadequate supervision, though many complaints were found unsubstantiated. Enforcement actions included staff suspensions and corrective plans, but no fines or license suspensions were listed in the available reports. The facility appears to have addressed many prior deficiencies, as the most recent inspection was clean following a period of mixed findings.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
181% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 96
Capacity: 96
Deficiencies: 0
Jun 20, 2025
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on May 2, 2025.
Findings
Brickyard Healthcare - Muncie 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 SNF/NF: 96
Census Payor Type Medicaid: 69
Census Payor Type Other: 27
Inspection Report
Life Safety
Census: 98
Capacity: 117
Deficiencies: 5
Jun 6, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements, including issues with exit door accessibility, exit discharge surfaces, exit signage, hazardous area door closures, and corridor door smoke resistance.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress for 1 of over 7 exit doors was readily accessible; door code was not posted in an obvious and readable manner. | SS=E |
| Failed to ensure all exit discharges had a level walking surface, were free of obstructions, and constructed of hard packed all-weather travel surface; exit discharge from dining hall had large cracks and uneven surface. | SS=E |
| Failed to ensure 1 of 1 riser room exit doors to the outside were not mistaken as a facility exit; door was marked as exit but opened to grass and lacked 'NO EXIT' sign. | SS=E |
| Failed to ensure 1 of over 6 hazardous area doors, such as storage rooms, were provided with properly working self-closing devices; kitchen storage room door lacked self-closing device. | SS=E |
| Failed to ensure all corridor doors would resist the passage of smoke; corridor door to Resident Room #224 would not latch and would not resist smoke passage. | SS=E |
Report Facts
Certified beds: 117
Census: 98
Residents affected: 5
Residents affected: 17
Residents affected: 2
Residents affected: 10
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaushik Patel | Executive Director | Signed the report |
| Maintenance Supervisor | Interviewed regarding deficiencies | |
| Assistant Maintenance Director | Interviewed regarding deficiencies |
Inspection Report
Annual Inspection
Census: 104
Capacity: 104
Deficiencies: 13
May 2, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from April 28 to May 2, 2025.
Findings
The facility was found deficient in multiple areas including failure to ensure proper consent signatures, failure to notify physicians of elevated blood pressures, failure to notify the Ombudsman of hospitalizations, failure to provide bed hold policy notifications, inadequate catheter care, failure to follow dietitian recommendations for weight loss, improper feeding tube care, incorrect oxygen administration, inadequate dementia care interventions, incomplete narcotic reconciliation, improper insulin labeling, and failure to offer pneumococcal and COVID-19 vaccines per CDC guidelines.
Severity Breakdown
SS=D: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure designated resident health care representative signed medical consent forms. | SS=D |
| Failed to notify physician of elevated blood pressures for 1 of 5 residents reviewed. | SS=D |
| Failed to provide notifications of hospitalization to the Long-Term Care Ombudsman for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure bed hold policies were provided to residents or responsible parties at hospital transfer for 2 of 3 residents reviewed. | SS=D |
| Failed to provide catheter care in a manner to reduce risk of contamination for 1 of 1 resident reviewed. | SS=D |
| Failed to follow Registered Dietitian recommendations and notify physician for significant weight loss for 1 of 4 residents reviewed. | SS=D |
| Failed to check feeding tube placement and prevent contamination during site care for 1 of 2 residents reviewed. | SS=D |
| Failed to follow physician orders regarding oxygen flow rate and humidity for 1 of 2 residents reviewed. | SS=D |
| Failed to provide individualized dementia care interventions to reduce psychoactive medication use for 1 of 4 residents reviewed. | SS=D |
| Failed to ensure shift to shift narcotic reconciliation was completed for 5 of 6 medication carts reviewed. | SS=D |
| Failed to ensure insulin was dated after opening and discarded when expired for 1 of 3 medication carts reviewed. | SS=D |
| Failed to offer and educate residents regarding Pneumococcal vaccines per CDC guidance for 1 of 5 residents reviewed. | SS=D |
| Failed to offer and educate residents regarding COVID-19 vaccines per CDC guidance for 1 of 5 residents reviewed. | SS=D |
Report Facts
Census: 104
Total Capacity: 104
Deficiency dates missing narcotic reconciliation: 30
Weight loss percentage: 7
Insulin expiration days: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaushik Patel | Executive Director | Signed the inspection report |
| LPN 3 | Provided information on narcotic count reconciliation | |
| LPN 9 | Observed performing feeding tube care with deficiencies | |
| LPN 13 | Observed medication cart and insulin labeling deficiencies | |
| DON | Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies |
| Administrator | Provided interview regarding consent and dementia care | |
| Social Services Director | Provided interview regarding consent and Ombudsman notifications | |
| CNA 10 | Provided interview regarding dementia resident behaviors | |
| QMA 11 | Provided interview regarding dementia resident behaviors | |
| Agency CNA 12 | Provided interview regarding dementia resident behaviors |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 99
Deficiencies: 0
Apr 7, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00453324.
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 regard to the Investigation of Complaint IN00453324.
Complaint Details
Complaint IN00453324 - No deficiencies related to the allegations are cited.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 74
Census Payor Type - Other: 23
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 10, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00451394 and IN00451774 completed on February 6, 2025.
Findings
Brickyard Healthcare - Muncie Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the investigations.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 1
Feb 5, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00451341, IN00451394, and IN00451774 at Brickyard Healthcare - Muncie Care Center.
Findings
The facility failed to follow physician-ordered parameters for blood pressure medication administration for 1 of 3 residents reviewed, resulting in medication being given outside prescribed parameters without proper documentation or indication. Three out of 17 residents with blood pressure medication parameters were affected by this deficient practice.
Complaint Details
Complaint IN00451341 had no deficiencies related to allegations. Complaints IN00451394 and IN00451774 had federal/state deficiencies cited at F684 related to medication administration outside physician ordered parameters.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow physician ordered parameters for medication administration related to blood pressure medication for 1 of 3 residents reviewed. | SS=D |
Report Facts
Residents affected: 3
Census: 98
Total capacity: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaushik Patel | Executive Director | Signed the report and plan of correction. |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 100
Deficiencies: 0
Sep 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442134.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00442134 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 100
Total Capacity: 100
Medicare Census: 5
Medicaid Census: 64
Other Payor Census: 31
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 0
Aug 28, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00440922 and was conducted in conjunction with a PSR to the Recertification and State Licensure Survey and Investigation of Complaint IN00436684 completed on 2024-07-12.
Findings
No deficiencies related to Complaint IN00440922 were cited. Complaint IN00436684 was corrected. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation.
Complaint Details
Complaint IN00440922 was investigated with no deficiencies cited. Complaint IN00436684 was corrected as of the prior survey date.
Report Facts
Census: 104
Total Capacity: 104
Medicare Census: 4
Medicaid Census: 69
Other Payor Census: 31
Inspection Report
Re-Inspection
Census: 104
Capacity: 104
Deficiencies: 0
Aug 28, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-07-12, including a PSR to the Investigation of Complaint IN00436684 completed on 2024-07-12, and was conducted in conjunction with an Investigation of Complaint IN00440922.
Findings
Brickyard Healthcare - Muncie 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 Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00436684. Complaint IN00436684 was corrected, and no deficiency related to Complaint IN00440922 was cited.
Complaint Details
Complaint IN00436684 was corrected. Complaint IN00440922 had no deficiency related to the allegation cited.
Report Facts
Census SNF/NF: 104
Total licensed capacity: 104
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 31
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 0
Aug 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440067.
Findings
No deficiencies related to the allegations in Complaint IN00440067 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00440067 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 98
Total Capacity: 98
Census Payor Type Medicaid: 67
Census Payor Type Other: 31
Inspection Report
Life Safety
Census: 99
Capacity: 117
Deficiencies: 1
Aug 1, 2024
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 08/01/2024 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to maintain means of egress free from obstructions in one corridor, specifically due to small plastic three drawer chests without wheels obstructing the corridor.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain means of egress free from obstructions in 1 of 8 corridors; small plastic three drawer chests holding personal protective equipment were not on wheels and obstructed the corridor. | SS=E |
Report Facts
Facility capacity: 117
Census: 99
Residents potentially affected: 16
Staff potentially affected: 4
Visitors potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to correcting the deficiency and acknowledging the issue | |
| Maintenance Assistant | Present during observation and discussion of deficiency | |
| Executive Director | Present during observation and exit conference discussing the deficiency |
Inspection Report
Life Safety
Deficiencies: 0
Aug 1, 2024
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and health care occupancy regulations.
Findings
Brickyard Healthcare - Muncie Care Center was found in compliance with the 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.
Inspection Report
Annual Inspection
Census: 98
Capacity: 98
Deficiencies: 8
Jul 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00436377, IN00436684, and IN00437298.
Findings
The facility was found deficient in multiple areas including failure to complete timely Significant Change Minimum Data Set (MDS) assessments, failure to maintain urinary drainage devices properly, failure to monitor fluid restrictions for dialysis patients, inadequate infection prevention and control practices including improper use of enhanced barrier precautions, failure to implement an antibiotic stewardship program, and lack of a qualified Infection Preventionist.
Complaint Details
Complaint IN00436377 - No deficiencies related to the allegations are cited. Complaint IN00436684 - Federal/state deficiencies related to the allegations are cited at F690. Complaint IN00437298 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure completion of a Significant Change Minimum Set (MDS) assessment within 14 days of a determined status change for 2 of 5 residents reviewed. | SS=D |
| Failed to ensure timely completion of Quarterly Minimum Data Set (MDS) assessments every three months for 1 of 5 residents reviewed. | SS=D |
| Failed to ensure timely submission of Minimum Data Set (MDS) assessments for 1 of 5 residents reviewed. | SS=D |
| Failed to provide consistent interventions to maintain urinary drainage devices for 2 of 3 residents reviewed. | SS=D |
| Failed to monitor the amount of fluids consumed by 1 or 2 residents on fluid restrictions reviewed for dialysis. | SS=D |
| Failed to implement and utilize infection prevention and control practices related to contact isolation, enhanced barrier precautions, and diagnostic testing for 3 of 5 residents reviewed for infection control. | SS=E |
| Failed to implement an antibiotic stewardship program per facility policy. | SS=E |
| Failed to designate one or more individual(s) as the Infection Preventionist with qualifying training or certification. | SS=F |
Report Facts
Census: 98
Total Capacity: 98
Residents with fluid restriction: 1
Infections reported: 19
Infections reported: 18
Residents receiving antibiotics: 19
Residents receiving antibiotics: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 12 | Infection Preventionist | Designated Infection Preventionist, promoted two months ago, not yet certified |
| RN 13 | Infection Preventionist Consultant | Part-time consultant for Infection Control Program, not involved since 2/5/24 |
| LPN 8 | Observed failing to wear gown in contact isolation and enhanced barrier precaution rooms | |
| CNA 9 | Provided information on contact isolation practices and resident care | |
| ADON | Assistant Director of Nursing / Infection Preventionist | Responsible for infection prevention program, acknowledged deficiencies |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 106
Deficiencies: 0
Jun 7, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00434914, IN00434584, and IN00435292.
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 regulations.
Complaint Details
Complaints IN00434914, IN00434584, and IN00435292 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 106
Total census: 106
Medicare census: 7
Medicaid census: 66
Other payor census: 33
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 0
May 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00431373 and IN00432660.
Findings
No deficiencies related to the allegations in Complaints IN00431373 and IN00432660 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00431373 and IN00432660 found no deficiencies related to the allegations.
Report Facts
Census: 102
Total Capacity: 102
Medicare Census: 2
Medicaid Census: 70
Other Payor Census: 30
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 0
Mar 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430202.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00430202 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 103
Census total residents: 103
Census Medicare residents: 5
Census Medicaid residents: 70
Census other payor residents: 28
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Mar 4, 2024
Visit Reason
This visit was for the investigation of complaints IN00428706, IN00429237, and IN00429273 at Brickyard Healthcare - Muncie Care Center.
Findings
No deficiencies related to the allegations in complaints IN00428706, IN00429237, and IN00429273 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding these complaints.
Complaint Details
Investigation of Complaints IN00428706, IN00429237, and IN00429273 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 97
Total census: 97
Medicare census: 3
Medicaid census: 71
Other payor census: 23
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 0
Feb 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427019 at Brickyard Healthcare - Muncie Care Center.
Findings
No deficiencies related to the allegations in Complaint IN00427019 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
Complaint IN00427019 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 102
Total Capacity: 102
Medicare Census: 5
Medicaid Census: 75
Other Payor Census: 22
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Nov 22, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419320, IN00421712, and IN00422242 at Brickyard Healthcare - Muncie Care Center.
Findings
No deficiencies related to the allegations in complaints IN00419320, IN00421712, and IN00422242 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00419320, IN00421712, and IN00422242 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 112
Total census: 112
Medicare census: 3
Medicaid census: 88
Other payor census: 21
Inspection Report
Complaint Investigation
Census: 105
Capacity: 105
Deficiencies: 0
Oct 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418615.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00418615 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 105
Census Payor Type Medicare: 4
Census Payor Type Medicaid: 82
Census Payor Type Other: 19
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 0
Sep 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416621.
Findings
No deficiencies related to the allegations in Complaint IN00416621 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00416621 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 4
Medicaid residents: 83
Other residents: 17
Inspection Report
Re-Inspection
Census: 106
Capacity: 106
Deficiencies: 0
Aug 31, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00414267 completed on August 3, 2023.
Findings
Brickyard Healthcare-Muncie Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00414267.
Complaint Details
Complaint IN00414267 - Corrected.
Report Facts
Census SNF/NF beds: 106
Census Medicare residents: 4
Census Medicaid residents: 87
Census Other residents: 15
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 2
Aug 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414267 and IN00413854. Complaint IN00414267 resulted in federal/state deficiencies cited, while Complaint IN00413854 had no deficiencies related to the allegations.
Findings
The facility failed to timely report allegations of abuse involving multiple residents and staff, and failed to report accurate information regarding some allegations. Specific incidents included rough handling and abuse by CNA 6 of Residents B and D, and an altercation involving Residents C and E. LPN 19 was suspended for failure to report abuse allegations promptly. The facility implemented corrective actions including staff education, audits, and monitoring to prevent recurrence.
Complaint Details
Complaint IN00414267 was substantiated with federal/state deficiencies cited at F600, F607, and F609. Complaint IN00413854 had no deficiencies related to the allegations.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report allegations of abuse immediately, resulting in abuse of a cognitively impaired resident. | SS=G |
| Failure to report timely allegations of abuse to the State Agency and failure to report accurate information regarding allegations of abuse. | SS=D |
Report Facts
Census: 102
Total Capacity: 102
Medicare Census: 3
Medicaid Census: 85
Other Payor Census: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaushik Patel | HFA | Facility representative who signed the report |
| LPN 19 | Nurse who failed to report abuse allegations and was suspended | |
| CNA 6 | Certified Nursing Assistant | Staff member involved in abuse allegations |
| CNA 7 | Certified Nursing Assistant | Staff member who reported abuse allegations |
| DON | Director of Nursing | Interviewed regarding abuse reporting and investigation |
Inspection Report
Follow-Up
Census: 108
Capacity: 108
Deficiencies: 0
Jul 24, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00410288 completed on June 21, 2023, conducted in conjunction with the Post Survey Revisit to the Recertification and State Licensure Survey completed on May 23, 2023.
Findings
Brickyard Healthcare - Muncie 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 IN00410288. The complaint was corrected.
Complaint Details
Complaint IN00410288 was investigated and found to be corrected.
Report Facts
Census SNF/NF: 108
Total Capacity: 108
Census Payor Type Medicare: 4
Census Payor Type Medicaid: 91
Census Payor Type Other: 13
Inspection Report
Re-Inspection
Census: 108
Capacity: 108
Deficiencies: 0
Jul 24, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on May 23, 2023, and was also in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00410288 completed on June 21, 2023.
Findings
Brickyard Healthcare-Muncie 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 Post Survey Revisit to the Recertification and State Licensure Survey.
Complaint Details
Investigation of Complaint IN00410288 was included in this Post Survey Revisit.
Report Facts
Census SNF/NF: 108
Total Capacity: 108
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 91
Census Payor Type - Other: 13
Inspection Report
Follow-Up
Census: 105
Capacity: 117
Deficiencies: 0
Jul 6, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 06/08/23.
Findings
At this Post Survey Revisit, Brickyard Healthcare Muncie was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 2
Jun 21, 2023
Visit Reason
This visit was for the investigation of complaints IN00410284, IN00410288, and IN00410832. The investigation focused on allegations related to medication administration and resident supervision.
Findings
The facility failed to ensure that Qualified Medication Aides (QMAs) who were not insulin-certified administered insulin to 6 residents. Additionally, the facility failed to provide adequate supervision and interventions to prevent two residents from leaving the facility property without staff knowledge.
Complaint Details
Complaint IN00410284 - No deficiencies related to the allegations are cited. Complaint IN00410288 - Federal/State deficiencies related to the allegation are cited at F659 (medication administration by unqualified QMAs). Complaint IN00410832 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure QMAs who were not insulin-certified did not administer insulin for 6 of 23 residents receiving insulin or injectable anti-diabetic medications. | SS=E |
| Facility failed to provide supervision and implement person-centered interventions to prevent residents from leaving the facility property without facility knowledge for 2 of 2 residents reviewed for elopement. | SS=D |
Report Facts
Residents receiving insulin: 23
Residents affected: 6
Residents reviewed for elopement: 2
Census: 101
Total capacity: 101
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaushik Patel | Executive Director | Signed the report |
| LPN 7 | Interviewed regarding resident supervision and elopement | |
| CNA 9 | Interviewed regarding residents exiting facility unsupervised | |
| DON | Director of Nursing | Provided information on QMA certification and facility policies |
| ADON | Assistant Director of Nursing | Spoke with resident regarding elopement event |
Inspection Report
Routine
Census: 106
Capacity: 117
Deficiencies: 3
Jun 8, 2023
Visit Reason
A routine Emergency Preparedness and Life Safety Code survey was conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements and state licensure.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, specifically failing to conduct required emergency plan exercises twice per year including unannounced staff drills, and not conducting annual 90-minute battery backup emergency light testing. Additionally, a multi-plug adaptor was found in use in a resident room, which is not compliant with electrical safety codes.
Deficiencies (3)
| Description |
|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures. |
| Failed to ensure 1 of 1 battery backup emergency light was tested annually for 90 minutes as required. |
| Failed to ensure resident room did not use multi-plug adaptors as a substitute for fixed wiring, violating electrical safety codes. |
Report Facts
Facility capacity: 117
Census: 106
Battery backup emergency light testing interval: 90
Number of battery backup emergency lights: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaushik Patel | Executive Director | Named as facility representative on the report |
Inspection Report
Annual Inspection
Census: 103
Capacity: 103
Deficiencies: 6
May 23, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 16 to May 23, 2023.
Findings
The facility was found deficient in several areas including failure to resolve resident council concerns about long call light wait times, failure to protect residents from sexual abuse, failure to follow physician orders for medication administration, failure to properly manage urinary catheters, failure to implement behavioral programming for sexually inappropriate behaviors, and medication administration errors related to insulin pen priming.
Severity Breakdown
E: 1
D: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to resolve resident council concerns related to long call light wait times. | E |
| Failure to protect a resident from sexual abuse by another resident with known sexually aggressive behavior. | D |
| Failure to follow physician's orders regarding acetaminophen medication administration parameters, resulting in doses exceeding recommended maximum. | D |
| Failure to ensure proper urinary catheter orders and management, including flushing and changing of suprapubic catheter. | D |
| Failure to develop and implement behavioral programming and diversion activities for resident with sexually inappropriate behaviors. | D |
| Failure to prime insulin pens prior to administration, resulting in medication administration errors. | D |
Report Facts
Census: 103
Total Capacity: 103
Medication administration error rate: 8
Medication administration opportunities: 25
Medication administration errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaushik Patel | Executive Director | Signed the inspection report |
| LPN 5 | Provided care for Resident 29 and discussed catheter management | |
| LPN 6 | Provided care for Resident 29 and discussed catheter management | |
| LPN 7 | On duty during sexual abuse incident involving Resident 59 | |
| LPN 11 | Observed administering insulin pens without priming | |
| QMA 12 | Qualified Medication Aide | Witnessed sexual abuse incident in dining room |
| Social Services Director | Provided information on Resident 59's sexual behavior history and interventions | |
| DON | Director of Nursing | Provided information on catheter and sexual behavior management |
| Activity Director | Unaware of diversion activities for Resident 59 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 17, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00403360 completed on March 21, 2023.
Findings
Brickyard Healthcare - Muncie Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00403360 completed on March 21, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 107
Capacity: 107
Deficiencies: 2
Mar 20, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00403360, which involved federal and state deficiencies related to allegations cited at F580 and F758.
Findings
The facility failed to ensure the resident representative was notified when a new psychotropic medication was started for one resident (Resident B). Additionally, the facility failed to ensure that a new psychotropic medication had an appropriate indication for use for the same resident. Resident B had behaviors including touching other residents and was started on Paxil without proper notification and documentation.
Complaint Details
Complaint IN00403360 was investigated, with deficiencies cited related to failure to notify resident representative of new psychotropic medication and failure to ensure appropriate indication for psychotropic medication use.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to notify resident representative when a new psychotropic medication was started. | SS=D |
| Failed to ensure new psychotropic medication had an appropriate indication for use. | SS=D |
Report Facts
Census: 107
Total Capacity: 107
Medicare residents: 7
Medicaid residents: 86
Other residents: 14
Psychotropic medication days: 7
Antidepressant medication days: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaushik Patel | Executive Director | Signed the report |
| LPN 6 | Interviewed regarding Resident B's behaviors and medication | |
| ACU Director | Interviewed regarding Resident B's behaviors and care | |
| LPN 12 | Interviewed about notification process for new medication orders | |
| QMA 4 | Interviewed about Resident B's behaviors | |
| DON | Director of Nursing | Interviewed regarding medication orders and policies |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 2
Feb 28, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00401123, IN00401809, and IN00402249 at Brickyard Healthcare - Muncie Care Center.
Findings
The facility was found to have substantiated complaints related to abuse and neglect involving staff and resident interactions, including physical abuse by a staff member and sexually inappropriate behaviors between residents. The facility failed to ensure timely reporting of abuse allegations. Corrective actions were completed prior to the survey.
Complaint Details
Complaint IN00401123 was substantiated with deficiencies cited at F600. Complaint IN00401809 was substantiated with deficiencies cited at F600 and F607. Complaint IN00402249 was substantiated but no deficiencies were cited related to the allegations.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to prevent physical abuse of a cognitively impaired resident by a staff member and failed to prevent sexually inappropriate behaviors between residents. | SS=G |
| Facility failed to develop and implement policies to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property, including timely reporting of allegations. | SS=D |
Report Facts
Census: 103
Total Capacity: 103
Bruise size: 4.8
Bruise size: 2.4
Days delay in reporting: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 17 | Certified Nursing Aide | Named in physical abuse finding involving Resident G |
| CNA 4 | Certified Nursing Aide | Named in physical abuse finding involving Resident G and delayed reporting incident |
| ED | Executive Director | Involved in escorting terminated employee and investigation |
| DON | Director of Nursing | Involved in investigation and statements regarding abuse incidents |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 20, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00397076 completed on December 29, 2022.
Findings
Brickyard Healthcare - Muncie 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
Investigation of Complaint IN00397076 completed with paper compliance review.
Inspection Report
Complaint Investigation
Census: 106
Capacity: 106
Deficiencies: 0
Jan 17, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00399084 and IN00398961.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00399084 - Substantiated with no deficiencies cited. Complaint IN00398961 - Substantiated with no deficiencies cited.
Report Facts
Census SNF/NF beds: 106
Census Medicare residents: 5
Census Medicaid residents: 93
Census Other residents: 8
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 1
Dec 29, 2022
Visit Reason
This visit was for the investigation of Complaints IN00394960 and IN00397076. Complaint IN00394960 was substantiated with no deficiencies cited, while Complaint IN00397076 was substantiated with federal/state deficiencies cited at F689.
Findings
The facility failed to ensure adequate supervision and individualized interventions to prevent falls for one resident (Resident D). The resident had multiple falls, including a fall resulting in a fractured hip, and the care plan was not adequately updated with additional interventions to reduce fall risk until after the incidents. The facility implemented corrective actions including audits, education, and ongoing monitoring to prevent recurrence.
Complaint Details
Complaint IN00394960 - Substantiated with no deficiencies cited. Complaint IN00397076 - Substantiated with federal/state deficiencies cited at F689.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and individualized interventions to prevent falls for Resident D. | SS=D |
Report Facts
Census: 104
Licensed capacity: 104
Medicare residents: 4
Medicaid residents: 87
Other residents: 13
Fall risk assessments: 4
Plan of correction monitoring frequency: 5
Plan of correction monitoring frequency: 3
Plan of correction monitoring frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Breque Norris | Executive Director | Signed as provider/supplier representative on the report |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 0
Nov 16, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393704.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00393704 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 104
Total Capacity: 104
Medicare Census: 4
Medicaid Census: 85
Other Payor Census: 15
Inspection Report
Complaint Investigation
Census: 106
Capacity: 106
Deficiencies: 0
Sep 27, 2022
Visit Reason
This visit was conducted for the Investigation of Complaint IN00390922.
Findings
The complaint IN00390922 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00390922 - Substantiated. No deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF beds: 106
Census total residents: 106
Census Medicare residents: 13
Census Medicaid residents: 75
Census other payor residents: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 23, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00389228 completed on September 7, 2022.
Findings
Brickyard Healthcare - Muncie Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00389228 completed on September 7, 2022; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 1
Sep 7, 2022
Visit Reason
This visit was conducted for the investigation of three complaints (IN00389256, IN00389435, and IN00389228). Complaints IN00389256 and IN00389435 were substantiated with no deficiencies cited, while complaint IN00389228 was substantiated with related federal/state deficiencies cited.
Findings
The facility failed to ensure a resident admitted with a suprapubic catheter received appropriate catheter care in accordance with professional standards upon admission. Specifically, catheter care orders were missing for eight days, and the facility did not obtain necessary orders or document catheter care, resulting in the resident being sent to the hospital for evaluation and treatment.
Complaint Details
Complaint IN00389256 - Substantiated with no deficiencies cited. Complaint IN00389435 - Substantiated with no deficiencies cited. Complaint IN00389228 - Substantiated with federal/state deficiencies cited at F684 related to quality of care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure appropriate catheter care for a resident admitted with a suprapubic catheter, including lack of catheter care orders and documentation for eight days. | SS=D |
Report Facts
Census: 104
Total Capacity: 104
Medicare Census: 8
Medicaid Census: 83
Other Payor Census: 13
Audit Frequency: 5
Audit Frequency: 3
Audit Frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to investigate lack of catheter care orders and inability to explain how the deficiency was missed | |
| Corporate Clinical Consultant | Interviewed and indicated failure to follow professional standards to obtain catheter care orders upon admission |
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