Inspection Reports for Brickyard Healthcare – Richmond Care Center
1042 OAK DR, IN, 47374
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 28, 2025, found the facility in compliance with no deficiencies cited during the post-survey revisit related to complaint investigations. Earlier inspections showed a pattern of deficiencies primarily involving resident care issues such as medication management, documentation, and safety during transfers, as well as some concerns with infection control and emergency preparedness. Complaint investigations occasionally substantiated deficiencies, including failures in care planning, timely treatment, and staff notification, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaints were either unsubstantiated or corrected upon follow-up, and the facility has demonstrated improvement over time, with recent inspections showing compliance after addressing prior issues. This suggests the facility has taken steps to resolve earlier deficiencies and maintain regulatory standards.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
431% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 68
Capacity: 68
Deficiencies: 0
Apr 28, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00454495 completed on March 5, 2025, conducted in conjunction with the Investigation of Complaint IN00457253.
Findings
Brickyard Healthcare - Richmond 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 IN00454495. Complaint IN00454495 was corrected.
Complaint Details
Complaint IN00454495 was corrected. The visit was related to investigations of complaints IN00454495 and IN00457253.
Report Facts
Census SNF/NF: 68
Census Medicare: 5
Census Medicaid: 60
Census Other: 3
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Apr 28, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00457253 and was in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00454495 completed on March 5, 2025.
Findings
No deficiencies related to the allegations of Complaint IN00457253 were cited. The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00457253 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 68
Total Capacity: 68
Medicare Census: 5
Medicaid Census: 60
Other Payor Census: 3
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 2
Mar 5, 2025
Visit Reason
This visit was for the investigation of complaints IN00453938 and IN00454495 related to allegations of resident safety and documentation issues.
Findings
The facility failed to ensure safe transfers for a resident resulting in a severe leg laceration requiring sutures, and failed to properly document a resident's death including notification to the physician and family.
Complaint Details
Complaint IN00453938 related to resident safety and accident hazards; Complaint IN00454495 related to resident records and documentation of death.
Severity Breakdown
Level G: 1
Level D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident received adequate assistance and supervision during transfer, resulting in an 18.5 cm leg laceration requiring 18 sutures. | Level G |
| Failed to document a resident's death, notify the physician, family, and properly document disposition and condition preceding death. | Level D |
Report Facts
Residents present: 64
Licensed capacity: 64
Sutures required: 18
Laceration length (cm): 18.5
Medicare residents: 7
Medicaid residents: 54
Other payor residents: 3
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Feb 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452451.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00452451 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 7
Medicaid census: 56
Other payor census: 2
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 12, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00446364 completed on November 12, 2024.
Findings
Brickyard Healthcare - Richmond 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
Complaint IN00446364 - Corrected.
Report Facts
Complaint number: 446364
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 8
Nov 6, 2024
Visit Reason
This visit was for the investigation of complaints IN00446761, IN00446364, and IN00446019 at Brickyard Healthcare - Richmond Care Center.
Findings
The facility was found deficient in multiple areas including failure to document clinically appropriate self-administration of medications, lack of proper code status orders and care plans, privacy violations by staff taking photos/videos on personal phones, failure to use smoking aprons for resident safety, lack of physician orders to crush medications, failure to monitor one-time medication orders, improper medication labeling and storage, and failure to maintain hospice orders and care plans.
Complaint Details
Complaint IN00446761 - No deficiencies related to the allegations cited. Complaint IN00446364 - Federal/State deficiencies related to the allegations cited at F554, F578, F583, F689, F755, F757, F761 and F849. Complaint IN00446019 - No deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to have interdisciplinary team determine and document self-administration of medications were clinically appropriate for 1 of 6 residents reviewed. | SS=D |
| Failed to ensure proper code status order and care plans were in place for 2 of 4 residents reviewed. | SS=D |
| Failed to provide privacy for residents by taking pictures and videos on personal cell phones for 2 of 4 residents reviewed. | SS=D |
| Failed to utilize smoking aprons during smoking for safety of 3 of 3 residents reviewed. | SS=D |
| Failed to obtain physician orders to crush medications for 3 of 5 residents reviewed. | SS=D |
| Failed to follow-up with monitoring and have indication for use on a one-time order for Ativan for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure open medication bottles were dated and had proper labeling; found un-identified medications in medication carts. | SS=E |
| Failed to ensure an order and care plan were in place for a resident receiving hospice services for 1 of 3 residents reviewed. | SS=D |
Report Facts
Census: 62
Total Capacity: 62
Medicare Census: 4
Medicaid Census: 57
Other Payor Census: 1
Deficiency Count: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Fortkamp | Director of Nursing Services | Named in medication administration and other findings |
| RN 1 | Registered Nurse | Interviewed regarding medication crushing and medication cart observations |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding medication cart observations and medication labeling |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding medication self-administration for Resident T |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding Resident W's condition and video documentation |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding privacy violation and photo of Resident KK's wound |
| Unit Manager | Provided policies related to medication self-administration and code status | |
| Executive Director | Provided policies related to medication storage and hospice services | |
| NP 2 | Nurse Practitioner | Provided orders for Resident W's Ativan administration |
Inspection Report
Life Safety
Census: 62
Capacity: 122
Deficiencies: 0
Nov 4, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/30/24 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Brickyard Healthcare - Richmond 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 (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinkled except for two detached wooden storage sheds.
Report Facts
Facility capacity: 122
Census: 62
Inspection Report
Annual Inspection
Census: 67
Capacity: 122
Deficiencies: 5
Sep 30, 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 09/30/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements, with multiple deficiencies noted including obstructed egress, improper kitchen equipment placement, inaccessible fire department connection, malfunctioning corridor doors, and improper use of power strips.
Severity Breakdown
SS=E: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 8 means of egress was continuously maintained free of all obstructions; a wheelchair was obstructing an exit door near Resident Room #52. | SS=E |
| Failed to provide an approved method for returning cooking appliances to their approved design location under the kitchen hood extinguishing system. | SS=E |
| Did not provide accessible access to the fire department connection (FDC); FDC and Post Indicator Valve were obstructed by parked cars. | — |
| Failed to ensure 5 of over 40 corridor doors had no impediment to closing and latching, including resident rooms and utility doors. | SS=E |
| Failed to ensure 1 of 1 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw; a power strip was used to power a microwave oven in the TCU Nurses Office. | SS=E |
Report Facts
Certified beds: 122
Census: 67
Corridor doors failed to latch: 5
Residents potentially affected by obstructed egress: 12
Staff potentially affected by kitchen equipment issue: 5
Staff potentially affected by power strip issue: 2
Staff potentially affected by corridor door issue: 8
Residents potentially affected by corridor door issue: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Bowman | Executive Director | Signed report and present at exit conference |
| Maintenance Supervisor | Acknowledged findings and participated in interviews and exit conference | |
| Regional Representative | Acknowledged findings and participated in interviews and exit conference |
Inspection Report
Annual Inspection
Census: 60
Capacity: 60
Deficiencies: 4
Sep 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00440948.
Findings
The facility was found deficient in multiple areas including failure to ensure proper self-administration of medications, failure to provide fresh water daily, failure to follow physician orders for weights and skin assessments, failure to implement proper infection control precautions, and failure to provide appropriate skin care for residents.
Complaint Details
Complaint IN00440948 was investigated during this survey, with federal/state deficiencies related to the allegations cited at F684.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure Resident 44 had a self-administration of medications assessment completed. | SS=D |
| Failed to provide fresh water daily for Resident C. | SS=D |
| Failed to follow physician orders for obtaining daily and monthly weights for Residents 6 and 44, and failed to have accurate skin assessments and heel protection for Resident C. | SS=D |
| Failed to don personal protective equipment (PPE) prior to entering the room of Resident 36 in contact isolation. | SS=D |
Report Facts
Survey dates: 7
Census: 60
Total capacity: 60
Medicare residents: 3
Medicaid residents: 49
Other payor residents: 8
Weight gain incidents: 11
Audit frequency: 3
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshal Bowman | HFA | Signed as Laboratory Director or Provider/Supplier Representative. |
| LPN 4 | Unit Manager | Educated staff on contact isolation and provided last treatment order for Resident C's rash. |
| DNS | Director of Nursing Services | Provided policies, interviewed regarding deficiencies, and described corrective actions. |
| CNA 11 | Failed to don PPE when entering Resident 36's room in contact isolation. | |
| CNA 13 | Observed not wearing PPE when providing care to Resident 36 in contact isolation. | |
| RN 1 | Registered Nurse | Provided information about Resident C's rash and care. |
| QMA 6 | Interviewed regarding Resident 44's medication nasal sprays. |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 13, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, along with an Investigation of Complaint IN00440948.
Findings
Brickyard Healthcare - Richmond 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 Annual Recertification, State Licensure, and Complaint Investigation.
Complaint Details
Investigation of Complaint IN00440948 was completed as part of the review.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 27, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00439896 and IN00440019 completed on August 5, 2024.
Findings
Brickyard Healthcare - Richmond 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 investigations.
Complaint Details
The visit was related to complaint investigations IN00439896 and IN00440019; compliance was found.
Report Facts
Complaint Investigation IDs: IN00439896 and IN00440019
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 2
Aug 5, 2024
Visit Reason
The visit was conducted for the investigation of multiple complaints (IN00440019, IN00439896, IN00437595, IN00435225, and IN00434048) regarding the facility.
Findings
The facility was found deficient in completing care plan meetings for residents and their representatives, and in notifying a resident's infectious disease physician of lab results related to antibiotic administration. Some complaints had no deficiencies related to the allegations.
Complaint Details
Complaint IN00440019 had deficiencies related to care plan meetings cited at F-553. Complaint IN00439896 had deficiencies related to medication administration cited at F-684. Complaints IN00437595, IN00435225, and IN00434048 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to complete care plan meetings for residents and their representatives for 2 of 3 residents reviewed. | SS=D |
| Failed to notify a resident's infectious disease physician of lab results and obtain labs as ordered prior to continuing antibiotic administration for 1 of 3 residents reviewed. | SS=D |
Report Facts
Census: 63
Total Capacity: 63
Medicare Census: 3
Medicaid Census: 54
Other Payor Census: 6
Vancomycin trough lab result: 26.5
Audit period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanne L Denney | Executive Director | Signed the report |
| RN 2 | Registered Nurse | Administered Resident E's last dose of Vancomycin and identified high trough levels |
| Director of Nursing | Director of Nursing | Provided lab results and pharmacy documentation regarding Resident E's Vancomycin management |
| Medical Director | Medical Director | Interviewed regarding Vancomycin dosing and management |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 6, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00433180 completed on May 6, 2024.
Findings
Brickyard Richmond 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 IN00433180 completed on May 6, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 1
May 6, 2024
Visit Reason
This visit was for the investigation of Complaints IN00432977 and IN00433180, which triggered a federal/state deficiency citation related to the allegations.
Findings
The facility failed to develop and implement a comprehensive care plan for seizure-like activities for one resident (Resident C) reviewed for falls. The Director of Nursing confirmed the absence of such care plans during the investigation.
Complaint Details
The investigation was triggered by Complaints IN00432977 and IN00433180. Deficiencies related to these complaints were cited at F689 and F656 respectively. The complaint investigation found the facility did not have a care plan for seizure-like activities for Resident C, substantiated by record review and interviews.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan for seizure-like activities for Resident C. | SS=D |
Report Facts
Census: 57
Total Capacity: 57
Medicare Residents: 3
Medicaid Residents: 46
Other Payor Residents: 8
Seizure-like activities documented: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Breque Norris | Area Vice President | Signed the report |
| Director of Nursing | Interviewed regarding lack of care plan for Resident C's seizure-like activities |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 2
Apr 18, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00417192, IN00421987, IN00428308, IN00429661, IN00430428, and IN00430802) regarding the facility's care and compliance.
Findings
The facility was found deficient in providing timely treatment and services to residents with pressure ulcers and incontinence associated dermatitis, resulting in worsening and infected pressure ulcers for two residents reviewed. The facility had no deficiencies related to some complaints but cited deficiencies related to complaints IN00428308 and IN00429661 at F686. The facility had corrected the deficient practice prior to the survey and implemented a wound management program.
Complaint Details
Complaints IN00417192, IN00421987, IN00430428, and IN00430802 had no deficiencies related to allegations. Complaints IN00428308 and IN00429661 were substantiated with deficiencies cited at F686 related to pressure ulcer care and treatment.
Severity Breakdown
SS=G: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident with an identified skin concern received timely treatment and services for an unstageable pressure ulcer that worsened and became infected (Resident E). | SS=G |
| Failed to ensure a resident received treatment for incontinence associated dermatitis who later developed a stage 3 pressure ulcer (Resident D). | SS=G |
Report Facts
Survey dates: April 16, 17, and 18, 2024
Census Bed Type: 62
Medicare census: 5
Medicaid census: 47
WBC count: 30000
Pressure ulcer size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding wound care deficiencies and corrective actions | |
| Assistant Director of Nursing | Assigned as primary person for wound management program | |
| Nurse Practitioner | Assisted with full skin sweep and wound assessments |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 28, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00419162, IN00419396 and unrelated deficiencies completed on October 23, 2023.
Findings
Brickyard Richmond 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 and unrelated deficiencies.
Complaint Details
The visit was related to complaint investigations IN00419162 and IN00419396; the facility was found in compliance.
Report Facts
Complaint Investigation IDs: IN00419162 and IN00419396
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 21, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to multiple complaint investigations (IN00409817, IN00415222, IN00418127, IN00418156, and IN00418208) completed on October 4, 2023.
Findings
Brickyard Richmond 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
The visit was related to complaint investigations identified by multiple complaint numbers. The facility was found to be in compliance based on the paper review.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 6
Oct 23, 2023
Visit Reason
This visit was for the investigation of complaints IN00419162 and IN00419396 related to allegations of abuse, neglect, quality of care, oxygen therapy, staffing, infection control, and sanitary conditions.
Findings
The facility was found deficient in multiple areas including failure to report and protect residents from abuse, inadequate quality of care for residents with changes in condition, failure to provide oxygen therapy per physician orders, insufficient nursing staff to meet resident needs, failure to prevent a staff member with gastrointestinal illness from working, and failure to maintain a sanitary environment as evidenced by a meal tray with maggots found in a resident's room.
Complaint Details
Complaint IN00419162 involved failure to report abuse, failure to provide quality care including timely hospital transfer, and failure to provide oxygen therapy. Complaint IN00419396 involved failure to report abuse, inadequate staffing, infection control issues, and sanitary environment concerns.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to report allegations of abuse and protect residents after abuse allegations for 3 of 13 residents reviewed. | SS=D |
| Failed to treat and assess a resident experiencing emesis and delayed hospital transport for 1 of 3 residents reviewed for quality of care. | SS=D |
| Failed to ensure oxygen therapy was provided according to physician orders for 1 of 3 residents reviewed for oxygen therapy. | SS=D |
| Failed to ensure adequate nursing staff to provide showers, toileting, transfers, and dining services for 38 of 55 residents on the Extended Care Unit. | SS=E |
| Failed to ensure a staff member did not work while experiencing symptoms of gastrointestinal illness. | SS=E |
| Failed to maintain a sanitary environment when a supper tray with maggots was found in a resident's dresser drawer. | SS=D |
Report Facts
Residents present: 56
Total licensed capacity: 56
Residents dependent on mechanical lift: 18
Residents needing assistance with feeding: 3
Residents needing assistance with eating: 4
Residents needing assistance with toileting: 6
Residents needing assistance with bathing: 37
Staffing ratio day shift: 10
Staffing ratio evening shift: 12
Staffing ratio night shift: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 10 | Certified Nursing Assistant | Worked while vomiting and febrile on 10/14/23 |
| LPN 19 | Licensed Practical Nurse | Cared for Resident K during fall and abuse allegation incident |
| CNA 2 | Certified Nursing Assistant | Involved in abuse allegation with Resident K |
| RN 21 | Registered Nurse | Cared for Resident C during change in condition |
| RN 22 | Registered Nurse | Assessed Resident C and sent to hospital |
| Executive Director | Executive Director | Facility leadership involved in investigation and staffing |
| Director of Nursing | Director of Nursing | Facility leadership involved in investigation and staffing |
| Restorative Aide 5 | Restorative Aide | Found meal tray with maggots in Resident E's room |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 4
Oct 3, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00409817, IN00415222, IN00417608, IN00418127, IN00418156, and IN00418208) regarding care and compliance issues at Brickyard Healthcare - Richmond Care Center.
Findings
The facility was found deficient in ensuring dependent residents received proper assistance with activities of daily living, timely and appropriate treatment and assessment of skin impairments, and complete and accurate documentation of medical and treatment records. Several residents had issues related to toileting assistance, pressure ulcer prevention and treatment, and medical record documentation.
Complaint Details
The investigation was triggered by complaints IN00409817, IN00415222, IN00417608, IN00418127, IN00418156, and IN00418208. Deficiencies related to these complaints were cited at tags F677, F686, and F842. Some complaints had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure a dependent resident received assistance and supervision with toileting, resulting in a fall. | SS=D |
| Failed to ensure skin impairments were assessed weekly, treatments initiated timely, and continued treatment provided for residents with skin impairments. | SS=D |
| Failed to maintain complete and accurate documentation of electronic medication administration records (MAR) and treatment administration records (TAR) for residents with skin impairments. | SS=D |
| Failed to maintain resident-identifiable information confidential and maintain complete medical records as required. | SS=D |
Report Facts
Residents reviewed for ADLs: 3
Residents reviewed for skin integrity: 4
Residents reviewed for medical record documentation: 4
Facility census: 58
Facility total capacity: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanne L Denney | Executive Director | Signed the report and involved in interviews regarding Resident D incident |
| Therapy Staff 6 | Provided statement regarding Resident D toileting incident | |
| CNA 8 | Certified Nursing Assistant | Failed to respond to care requests related to Resident D toileting |
| CNA 10 | Certified Nursing Assistant | Found Resident D on bathroom floor after fall |
| CNA 4 | Certified Nursing Assistant | Provided information about Resident B's skin condition |
| LPN 3 | Licensed Practical Nurse | Discussed Resident B's skin assessment with Director of Nursing |
| Director of Nursing | Director of Nursing | Provided information about skin assessments and wound care |
| Wound Nurse | Provided wound care information for Residents B, D, and E | |
| Corporate Nurse | Provided wound treatment management policy |
Inspection Report
Follow-Up
Census: 58
Capacity: 122
Deficiencies: 0
Jul 20, 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 06/06/23 by the Indiana Department of Health.
Findings
At the Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility 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.
Report Facts
Certified beds: 122
Census: 58
Inspection Report
Re-Inspection
Census: 54
Capacity: 54
Deficiencies: 0
Jun 30, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and PSR to the Investigation of Complaints IN00406095, IN00407646, and IN00408060 completed on May 22, 2023.
Findings
Brickyard Healthcare - Richmond 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 and PSR to Investigation of Complaints IN00406095, IN00407646, and IN00408060. All complaints were corrected.
Complaint Details
Complaints IN00406095, IN00407646, and IN00408060 were investigated and found to be corrected.
Report Facts
Census SNF/NF: 54
Census Payor Type Medicare: 4
Census Payor Type Medicaid: 46
Census Payor Type Other: 4
Inspection Report
Life Safety
Census: 52
Capacity: 122
Deficiencies: 8
Jun 6, 2023
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). The survey included evaluation of emergency preparedness and compliance with fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards including deficiencies in emergency preparedness planning, emergency power system maintenance, egress door locking, corridor door latching, smoke barrier door functionality, occupational therapy office smoke detection, and smoking area maintenance.
Severity Breakdown
SS=C: 2
SS=E: 4
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to maintain an emergency preparedness plan based on a documented facility-based and community-based risk assessment utilizing an all-hazards approach. | SS=C |
| Failed to develop and maintain a complete emergency preparedness communication plan with current contact information. | SS=C |
| Failed to implement emergency power system inspection, testing, and maintenance requirements including lack of annual fuel quality test for diesel generator. | SS=F |
| Failed to ensure means of egress doors were readily accessible and not equipped with locks requiring a tool or key from the egress side without proper clinical justification. | SS=E |
| Failed to ensure occupational therapy office with pass-through window greater than 20 square inches was protected by electrically supervised smoke detection. | SS=E |
| Failed to ensure corridor doors had no impediment to closing and latching into the door frame. | SS=E |
| Failed to ensure smoke barrier doors would restrict the movement of smoke for at least 20 minutes as required. | SS=E |
| Failed to maintain smoking areas by disposing cigarette butts in metal or noncombustible containers with self-closing covers. | SS=F |
Report Facts
Certified beds: 122
Census: 52
Deficiencies cited: 8
Fuel quality test date: Apr 7, 2022
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 1, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00404542, IN00404629, and IN00405188 completed on April 5, 2023.
Findings
Brickyard Richmond 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 IN00404542, IN00404629, and IN00405188. The facility was found in compliance based on paper review.
Report Facts
Complaint Investigation IDs: IN00404542, IN00404629, IN00405188
Inspection Report
Inspection Report
Census: 49
Capacity: 49
Deficiencies: 18
May 22, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including investigation of Complaints IN00406095, IN00407646, and IN00408060, resulting in an Extended Survey with Substandard Quality of Care - Immediate Jeopardy.
Findings
The facility was found deficient in multiple areas including reasonable accommodations, abuse/neglect policies, notice requirements before transfer/discharge, accuracy of assessments, comprehensive care plans, activities of daily living, activities programming, quality of care, dialysis services, infection control, immunizations, and personnel files. Specific issues included failure to provide specialty cups, delayed abuse reporting, incomplete transfer documentation, inaccurate MDS assessments, incomplete care plans, inadequate ADL care, lack of activity engagement, delayed pain management, incomplete dialysis documentation, incomplete infection surveillance, and missing employee file documentation.
Complaint Details
Complaint IN00406095 and IN00407646 were substantiated with federal/state deficiencies cited at F677. Complaint IN00408060 was substantiated with deficiencies cited at F600.
Severity Breakdown
SS=D: 13
SS=E: 4
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to provide specialty cups and hydration accommodations as ordered for residents. | SS=D |
| Failed to ensure timely reporting of physical and verbal abuse for a resident. | SS=D |
| Failed to provide proper notice and documentation before transfer or discharge for residents. | SS=D |
| Inaccurate Minimum Data Set (MDS) assessments regarding mood, behavior, vision, and pain. | SS=D |
| Failed to develop comprehensive care plans for hypothyroidism and constipation. | SS=D |
| Failed to provide assistance with activities of daily living including grooming and nail care. | SS=E |
| Failed to provide ongoing activity programs meeting resident interests and preferences. | SS=D |
| Failed to provide quality of care including proper preparation for procedures, neurological assessments post-fall, splinting, and weekly weights. | SS=D |
| Failed to ensure range of motion and assistive devices were properly used and documented. | SS=D |
| Failed to provide adequate supervision during meals, implement fall interventions, and ensure resident whereabouts. | SS=D |
| Failed to monitor enteral feeding intake totals and follow up on residuals as ordered. | SS=D |
| Failed to provide adequate pain management and follow up on ineffective pain medication. | SS=D |
| Failed to ensure complete documentation of pre and post dialysis evaluations. | SS=D |
| Failed to provide adequate treatment and interventions for a resident with dementia exhibiting agitation and combativeness. | SS=D |
| Failed to ensure monthly pharmacist drug regimen reviews were reviewed and acted upon by the provider. | SS=E |
| Failed to maintain an infection control program with consistent infection mapping and tracking for 11 of 12 months. | SS=E |
| Failed to ensure influenza and pneumococcal immunizations were offered and/or administered and documented for residents. | SS=D |
| Failed to maintain complete employee files including references, tuberculosis testing, physical exams, and required training. | SS=E |
Report Facts
Survey dates: 2023-05-15 to 2023-05-22
Census: 49
Total Capacity: 49
Deficiency counts: 17
Weight measurements: 190.2
Weight measurements: 101.8
Weight measurements: 94
Pressure ulcer size: 1.34
Pressure ulcer size: 0.87
Pressure ulcer size: 2.15
Pressure ulcer size: 1.6
Tube feeding rate: 65
Tube feeding flush: 90
Tube feeding flush: 30
Medication dosage: 50
Medication dosage: 100
Medication dosage: 30
Medication dosage: 20
Medication dosage: 5
Medication dosage: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Hestand | Regional Director of Clinical Operations | Signed report cover page |
| Family Member 8 | Reported abuse incident observed on camera for Resident B | |
| CNA 2 | Certified Nursing Assistant | Named in abuse incident with Resident B |
| CNA 4 | Certified Nursing Assistant | Named in abuse incident with Resident B |
| Director of Nursing | Director of Nursing | Reviewed video footage of abuse incident |
| Regional Vice President | Regional Vice President | Provided policies and interviews about deficiencies |
| Administrator | Administrator | Interviewed about multiple deficiencies and facility policies |
| Unit Manager | Unit Manager | Interviewed about fall interventions and resident supervision |
| Maintenance Director | Maintenance Director | Interviewed about TV not working |
| Family Member 8 | Reported abuse incident observed on camera for Resident B |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 4
Apr 5, 2023
Visit Reason
This visit was for the investigation of complaints IN00404542, IN00404629, and IN00405188.
Findings
The facility was found deficient in multiple areas including failure to provide fluids throughout the day for residents, failure to conduct weekly skin assessments and timely catheter care, failure to administer intravenous antibiotics timely and fully, and incomplete documentation in medication and treatment records as well as lack of readmission assessments.
Complaint Details
This visit was complaint-related for complaints IN00404542, IN00404629, and IN00405188. Deficiencies were substantiated as cited in the report.
Severity Breakdown
E: 2
D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure residents were provided fluids throughout the day for 5 residents. | E |
| Failed to ensure weekly skin assessments were conducted and urinary catheter care was timely for 2 residents. | D |
| Failed to ensure intravenous antibiotics were administered timely and fully and medications in emergency drug kit were administered for 2 residents. | D |
| Failed to ensure complete documentation in electronic medication and treatment administration records and conduct readmission assessments for 5 residents. | E |
Report Facts
Residents interviewed for hydration deficiency: 5
Residents reviewed for change in condition: 4
IV antibiotic doses administered: 27
IV antibiotic doses scheduled: 42
Pages reviewed in EMAR/ETAR: 31
Medication/treatment documentation holes: 80
Pages reviewed in EMAR/ETAR: 37
Medication/treatment documentation holes: 35
Pages reviewed in EMAR/ETAR: 40
Medication/treatment documentation holes: 95
Pages reviewed in EMAR/ETAR: 36
Medication/treatment documentation holes: 47
Pages reviewed in EMAR/ETAR: 49
Medication/treatment documentation holes: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Hestand | Regional Director of Clinical Operations | Signed the report |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 20, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00394792 completed on January 30, 2023.
Findings
Brickyard Richmond 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 IN00394792 completed on January 30, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 3
Jan 26, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00387720, IN00388299, IN00391807, IN00394742, and IN00400058) regarding care and compliance issues at the facility.
Findings
The facility was found to have substantiated deficiencies related to notification of changes in condition and quality of care for Resident F, including failure to follow up on significant laboratory changes, failure to obtain daily weights, and failure to assist with a cardiology appointment as ordered. Some complaints were unsubstantiated or substantiated with no deficiencies cited.
Complaint Details
Complaint IN00387720 was unsubstantiated due to lack of evidence. Complaint IN00388299 was substantiated with no deficiencies cited. Complaint IN00391807 was unsubstantiated due to lack of evidence. Complaint IN00394742 was substantiated with federal/state deficiencies cited at F580 and F684. Complaint IN00400058 was substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to follow up on a significant change of laboratory work for Resident F. | SS=D |
| Failed to notify physician or resident representative promptly of changes including injury, decline, or room changes. | SS=D |
| Failed to obtain daily weights and assist Resident F with a cardiology appointment as ordered. | SS=D |
Report Facts
Census: 54
Total Capacity: 54
Deficiencies cited: 3
Survey dates: January 26, 27, and 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn M Steele | ED, HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 4 | Interviewed regarding Resident F's care and lab review | |
| MD | Physician | Interviewed regarding Resident F's hospitalization and lab work |
| Clinical Regional Support | Interviewed regarding daily weights and physician orders |
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