Inspection Reports for Brickyard Healthcare – Petersburg Care Center
309 W PIKE AVE, IN, 47567
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 25, 2024, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies involving resident care documentation, infection control practices, and environmental maintenance. Prior reports cited issues such as missed wound treatment orders, improper use of personal protective equipment by staff, and inadequate reporting of significant resident condition changes. Complaint investigations were mostly unsubstantiated, with the exception of a few substantiated complaints that resulted in citations but no enforcement actions or fines were listed in the available reports. The facility’s record shows some improvement in recent months, with the latest inspections indicating compliance and correction of previously cited issues.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a November 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 0
Nov 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446318.
Findings
No deficiencies were cited related to the allegations in Complaint IN00446318. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00446318 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 43
Census Medicare residents: 2
Census Medicaid residents: 38
Census Other residents: 3
Inspection Report
Life Safety
Census: 49
Capacity: 86
Deficiencies: 0
Sep 18, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Brickyard Healthcare-Petersburg 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. The facility is fully sprinklered except for three detached structures: a detached garage, a portable wood shed, and a wood shed for the water softener.
Report Facts
Facility capacity: 86
Census: 49
Inspection Report
Life Safety
Census: 44
Capacity: 86
Deficiencies: 2
Aug 21, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101, Chapter 19, Existing Health Care Occupancies.
Findings
The facility was found not in compliance with Life Safety Code requirements, specifically failing to ensure the fire department connection had proper signage and the oxygen storage room had a working mechanical ventilation system. Corrective actions were planned and requested for paper compliance.
Severity Breakdown
SS=F: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure fire department connection (FDC) was properly identified with signage. | SS=F |
| Failed to ensure oxygen storage room had properly working mechanical ventilation. | SS=E |
Report Facts
Facility capacity: 86
Census: 44
Deficiency completion date: Aug 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Eckert | Executive Director | Named during exit conference and report signature |
| Maintenance Director | Interviewed regarding fire department connection signage and mechanical ventilation deficiencies | |
| Maintenance Assistant | Participated in facility tour and exit conference regarding deficiencies |
Inspection Report
Annual Inspection
Census: 42
Capacity: 42
Deficiencies: 4
Aug 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00437005.
Findings
The facility was found deficient in accommodating resident needs for call lights, accuracy of Minimum Data Set (MDS) assessments, dialysis care and documentation, and maintaining a safe, clean, and homelike environment including water temperature control and room maintenance.
Complaint Details
Complaint IN00437005 was investigated during this visit, with federal/state deficiencies related to the allegations cited at F921.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to accommodate resident needs for call lights within reach for 2 of 13 residents reviewed. | SS=D |
| Failed to ensure Minimum Data Set (MDS) Assessments were completed accurately for 3 of 8 resident MDS Assessments reviewed. | SS=D |
| Failed to ensure necessary care and complete assessments were provided for 1 of 1 residents reviewed for dialysis; lacked post dialysis assessment documentation and current dialysis contract. | SS=D |
| Failed to ensure a clean and homelike environment for 6 of 13 resident rooms and 1 of 2 shower rooms; issues included holes in walls, exposed pipes, peeling baseboards, uncovered bedpans, badly scuffed floors, air conditioner unit falling off wall, and multiple sink water temperatures exceeding 120 degrees Fahrenheit. | SS=E |
Report Facts
Census: 42
Total Capacity: 42
Water Temperature: 127.5
Water Temperature: 124.2
Water Temperature: 123.6
Water Temperature: 123.3
Water Temperature: 122.9
Water Temperature: 120.8
Water Temperature: 120.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 14 | Certified Nurse Aide | Interviewed regarding call light accessibility for residents |
| LPN 26 | Licensed Practical Nurse | Interviewed regarding Resident 38's care and Wander Guard usage |
| LPN 44 | Licensed Practical Nurse | Interviewed regarding dialysis form completion process |
| Regional Nurse | Interviewed regarding MDS assessment accuracy and policies | |
| Administrator | Provided policies and information on call light and dialysis procedures | |
| Maintenance Assistant | Interviewed regarding water temperature monitoring and maintenance issues | |
| DON | Director of Nursing | Provided dialysis communication forms and policies |
Inspection Report
Deficiencies: 0
Aug 9, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Recertification and State Licensure survey and the Investigation of Complaint IN00437005 survey ending on August 9, 2024.
Findings
Brickyard Healthcare - Petersburg 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 Recertification, State Licensure Survey, and the Investigation of Complaint IN00437005 Survey.
Complaint Details
Investigation of Complaint IN00437005 was included in the survey; no deficiencies were found.
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 0
Feb 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00424988.
Findings
No deficiencies were cited related to the allegations. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Investigation of Complaint IN00424988 found no deficiencies related to the allegations.
Report Facts
Census: 48
Total Capacity: 48
Census payor type - Medicare: 1
Census payor type - Medicaid: 41
Census payor type - Other: 6
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 1
Nov 16, 2023
Visit Reason
This visit was for the investigation of complaints IN00415321 and IN00420720. Complaint IN00415321 resulted in federal/state deficiencies related to the allegations, while Complaint IN00420720 had no deficiencies cited.
Findings
The facility failed to ensure treatment orders were put in place and weekly wound measurements were documented for one of three residents reviewed (Resident B). Resident B had diabetic foot ulcers and chronic osteomyelitis, but wound treatment orders were missed and wound measurements were not consistently recorded. The resident was non-compliant with treatments and missed wound clinic appointments. The facility lacked documentation of notifying the physician about missed appointments and non-compliance.
Complaint Details
Complaint IN00415321 was substantiated with federal/state deficiencies cited. Complaint IN00420720 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure treatment orders were in place and weekly wound measurements documented for Resident B with diabetic foot ulcers and chronic osteomyelitis. | SS=D |
Report Facts
Census: 42
Total Capacity: 42
Survey Dates: November 14, 15, 16, 2023
Medicare Residents: 2
Medicaid Residents: 38
Other Payor Residents: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Eckert | Executive Director | Signed the report |
| Director of Nursing (DON) | Provided information about Resident B's wound care and non-compliance | |
| LPN 1 | Provided information about Resident B's care and non-compliance | |
| MDS Coordinator | Mentioned in relation to care plans and non-compliance documentation; no full name provided |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 16, 2023
Visit Reason
Paper compliance review for the Post Survey Revisit (PSR) to the Investigation of Complaint IN00415321 survey ending on November 16, 2023.
Findings
Brickyard Healthcare - Petersburg 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 Post Survey Revisit (PSR) to the Investigation of Complaint IN00415321 survey.
Complaint Details
Investigation of Complaint IN00415321; paper compliance review found in compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 22, 2023
Visit Reason
Paper compliance review for the Post Survey Revisit (PSR) to the Post Survey Revisit to Recertification and State Licensure Survey ending on August 30, 2023.
Findings
Brickyard Healthcare - Petersburg 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 Post Survey Revisit to Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 41
Capacity: 41
Deficiencies: 0
Aug 30, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00413866 completed on August 3, 2023, conducted in conjunction with the Recertification and State Licensure Survey completed on June 22, 2023.
Findings
Brickyard Healthcare Petersburg 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 IN00413866. The complaint was corrected.
Complaint Details
Complaint IN00413866 was investigated and found to be corrected.
Report Facts
Census SNF/NF beds: 41
Total census: 41
Medicaid census: 39
Other payor census: 2
Inspection Report
Re-Inspection
Census: 41
Capacity: 41
Deficiencies: 2
Aug 30, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on June 22, 2023, conducted in conjunction with the Investigation of Complaint IN00413866 completed on August 3, 2023.
Findings
The facility failed to ensure a safe and sanitary environment to prevent the development and transmission of infections. Specifically, nursing staff did not wear proper personal protective equipment (PPE) during incontinence care and insulin administration for residents on Enhanced Barrier Precautions (EBP).
Complaint Details
The visit was conducted in conjunction with the investigation of Complaint IN00413866.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Nursing staff failed to wear proper PPE while performing incontinence care on Resident 12, including failure to wear gowns and proper handling of supplies. | SS=D |
| Nursing staff failed to wear gloves when administering insulin injection to Resident 182 on Enhanced Barrier Precautions. | SS=D |
Report Facts
Census: 41
Total Capacity: 41
Deficiencies cited: 2
Audit frequency: 5
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 12 | Certified Nurse Aide | Observed failing to wear proper PPE during incontinence care |
| CNA 24 | Certified Nurse Aide | Observed failing to wear proper PPE during incontinence care |
| RN 6 | Registered Nurse | Observed failing to wear gloves during insulin administration |
| Cathy Eckert | Laboratory Director's or Provider/Supplier Representative | Signed the report |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Aug 9, 2023
Visit Reason
This visit was for the investigation of complaint IN00414786.
Findings
No deficiencies were cited related to the allegations. 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 complaint investigation.
Complaint Details
Investigation of complaint IN00414786 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 46
Census total residents: 46
Census payor types Medicare: 1
Census payor types Medicaid: 42
Census payor types Other: 3
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 1
Aug 3, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00412618 and IN00413866. Complaint IN00412618 had no deficiencies cited, while complaint IN00413866 resulted in federal/state deficiencies related to PICC line care.
Findings
The facility failed to ensure staff had the skills, experience, and knowledge to provide care related to PICC line services for 2 residents. Residents missed antibiotic doses, lab results were not obtained timely, and staff were not in-serviced on PICC line care.
Complaint Details
Complaint IN00413866 was substantiated with federal/state deficiencies cited. Complaint IN00412618 had no deficiencies related to allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure staff had the skills, experience, and knowledge to provide care related to PICC line services for 2 residents, resulting in missed antibiotic doses and delayed lab results. | SS=D |
Report Facts
Census: 44
Total Capacity: 44
Missed Vancomycin doses: 5
Missed Daptomycin doses: 2
Survey dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Eckert | Executive Director | Signed the report |
| Yvonne Tanner | DNS/designee | Responsible for reviewing physician orders 5 times per week to ensure intravenous orders are complete |
| Jennifer Whitlock | RN, MSN, FN | Author of PICC line training used for staff education |
Inspection Report
Life Safety
Census: 43
Capacity: 86
Deficiencies: 0
Jul 24, 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 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 and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility is a one-story, fully sprinklered Type V (111) construction with a fire alarm system and smoke detectors. Some detached structures used for storage were not sprinklered.
Report Facts
Facility capacity: 86
Census: 43
Detached structures not sprinklered: 3
Inspection Report
Annual Inspection
Census: 43
Capacity: 43
Deficiencies: 6
Jun 22, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted June 19-22, 2023.
Findings
The facility was found deficient in multiple areas including failure to notify physicians and family of significant resident condition changes, respiratory care deficiencies, inaccurate nurse staffing postings, medication errors, unappetizing food served at unsafe temperatures, and inadequate infection control practices.
Severity Breakdown
SS=D: 4
SS=C: 1
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure significant changes in residents' health conditions were reported to physicians and family. | SS=D |
| Failed to provide necessary respiratory care including following physician oxygen orders and documenting oxygen use. | SS=D |
| Failed to post accurate daily nurse staffing information. | SS=C |
| Medication error rate exceeded 5%, including use of outdated insulin pens and incorrect medication dosages. | SS=D |
| Failed to provide palatable, attractive, and safe temperature food; residents complained of unappetizing food and varying temperatures. | SS=D |
| Failed to ensure proper infection control practices during medication administration and incontinence care, including hand hygiene and glove use. | SS=E |
Report Facts
Census: 43
Total Capacity: 43
Medication error rate: 7.14
Temperature: 116.6
Temperature: 110.1
Temperature: 42.8
Entree meat temperature: 186
Vegetable temperature: 191
Starch temperature: 178
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Eckert | Executive Director | Signed report |
| RN 5 | Registered Nurse | Interviewed regarding notification of changes and resident assessments |
| QMA 3 | Qualified Medication Aide | Observed and interviewed regarding incontinence care and oxygen saturation monitoring |
| CNA 7 | Certified Nurse Aide | Observed providing incontinence care |
| LPN 18 | Licensed Practical Nurse | Observed medication administration and interviewed regarding medication errors |
| RN 20 | Registered Nurse | Interviewed regarding medication order discrepancy |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including notification, respiratory care, staffing, medication, and infection control |
| ADON | Assistant Director of Nursing | Interviewed regarding hand hygiene and medication administration policies |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperatures and palatability |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Jan 12, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00393057.
Findings
The complaint IN00393057 was substantiated, but no deficiencies were cited related to the allegations. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00393057 was substantiated with no deficiencies cited related to the allegations.
Report Facts
Census bed type: 44
Census payor type Medicaid: 41
Census payor type Other: 3
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