No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Brickyard Healthcare - Bloomington Care Center

155 E Burks Dr, Bloomington, IN 47401 · For profit - Corporation · 153 certified beds · (812) 332-4437 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 20241 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$9,249 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $9,249 in federal fines (most recent 2025-04-03)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
333 E Miller Dr · (812) 353-3244 · Call to confirm hours
Pharmacy
2650 S Walnut St · (812) 336-6223 · Call to confirm hours
Grocery
Kroger0.5 mi
4025 S Old State Road 37 · (812) 803-7240 · Call to confirm hours
Park
Sherwood Oaks Park, 1600 E Elliston Dr · (812) 349-3700 · Typically dawn to dusk
Place of worship
3291 S Walnut St Pike · (812) 333-5373

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.6%11.0%15.4%better
Long-stay residents who lose too much weight5.9%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.7%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.4%1.1%2.0%better
Long-stay residents with depressive symptoms6.1%25.2%6.5%typical
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.3%3.9%3.3%typical
Long-stay residents whose ability to walk worsened9.0%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication36.9%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine90.2%95.4%95.3%typical
Long-stay residents with pressure ulcers3.7%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control28.4%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table31.8%13.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.8%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine40.9%79.0%79.4%worse
Short-stay residents rehospitalized after admission25.6%22.2%22.6%worse
Short-stay residents with an outpatient ER visit7.8%10.8%12.0%better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

43.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.6%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
30.0%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 30.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF43.6%CMS range 29.6–59.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.3–14.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge30.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge40.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.0%CMS range 4.5–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.54
RN hours/ resident / day
0.81
LPN hours/ resident / day
1.68
Aide hours/ resident / day
3.03
Total nurse hours/ resident / day
0.41
RN hoursweekends
49.5%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 153 beds and averages 121.8 residents a day — about 80% occupied, or roughly 31 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.03 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.68 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.77 hrs/resident/day on weekends vs 3.13 on weekdays — 12% thinner on weekends. RN hours go from 0.59 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2025-04-25)
6
at the previous standard inspection (2024-06-24)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    A. Based on observation, interview and record review, the facility failed to provide supervision to prevent a cognitively impaired resident with a history of exit seeking behavior from leaving the facility property without staff knowledge for 1 of 3 residents reviewed. (Resident B)B. Based on observation, interview, and record review, the facility failed to ensure the secured unit courtyard gate was locked for 2 of 3 observations. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 5/8/26 at approximately 9:30 a.m. when the facility failed to provide supervision to prevent a cognitively impaired resident with a history of exit seeking behavior from leaving the facility property for an unknown amount of time without staff knowledge. The Administrator, the Director of Nursing, the Regional Nurse were notified of the Immediate Jeopardy on 5/13/23 at 3:45 p.m. The Immediate Jeopardy was removed on 5/14/26 at 1:30 p.m., but noncompliance remained at a lower scope and severity level of isolated, no actual harm with potential for more than minimal…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2025-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide supervision to prevent a cognitively impaired resident, who had an appointed guardian and history of exit seeking, from exiting the facility without staff knowledge for 1 of 3 residents reviewed for elopements. This deficient practice resulted in the resident being located by local law enforcement 1.8 miles away. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 3/29/25 at approximately 9:45 p.m., when the facility failed to prevent a cognitively impaired resident from leaving the facility without staff knowledge. The Area [NAME] President and Regional Nurse were notified of the Immediate Jeopardy on 4/2/25 at 12:20 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, on 3/30/25, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: During an interview on 4/2/25 at 8:06 a.m., LPN 1 indicated she arrived at work on 3/29/25 at approximately 10:50 p.m. Resident B had already left the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-07-15 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect the resident's right to be free from physical restraints for 1 of 4 residents reviewed for restraints. A restraint was applied by unlicensed personnel, there was no physician's order, consent, or documentation for release of the restraint. (Resident B, CNA 3)Finding includes:On 7/14/25 at 12:00 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia affecting right dominant side (paralysis or severe weakness on the right side of the body), dementia, and aphasia (a language disorder that affects the ability to communicate).A progress note, dated 6/26/25 at 5:59 p.m., indicated an incident was reported by CNA 1 that when she came on shift, Resident B was noted to have a sock tied around his left hand. The CNA reported the observation to a licensed nurse. A head-to-toe assessment was completed by the licensed nurse, the resident was noted to have swelling of his left hand and red linear indentation (indentation that is long and narrow) on his left wrist.A Care Plan,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-25 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike environment free of damage, disrepair, and odor of urine for 1 of 2 secured units and 5 of 7 resident rooms reviewed for environment. (Reflections 2 Unit, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. On 4/23/25 at 1:20 p.m., 4/24/25 at 2:10 p.m., and 4/25/25 at 10:40 a.m., the bathroom off the dining room on the Reflections 2 unit was observed to emit a strong odor of urine and had brown stained substance around the base of the toilet. 2. On 4/25/25 at 10:45 a.m., the 2 shower room stalls in the Reflections 2 unit shower room were observed to have a brown stained substance around the junctions where the walls meet the floors. 3. On 4/25/25 at 10:50 a.m., the base of the bathroom door in the Lounge room [ROOM NUMBER] was observed to have broken wall board. 4. On 4/25/25 at 10:55 a.m., room [ROOM NUMBER] was observed to have damaged drywall a the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 1 of 1 resident reviewed for hospitalization. (Resident 53) Findings include: Resident 53's clinical record was reviewed on 4/23/25 at 2:15 p.m. The diagnoses included, but were not limited to, congestive heart failure and kidney failure. Resident 53's progress notes indicated the resident was sent to the hospital on 1/9/25 and 3/11/25. The clinical record lacked documentation of written notification of the transfer and discharge forms having been provided to the resident and the resident representative. During an interview on 4/24/25 at 12:11 p.m., the Director of Nursing Services (DNS) indicated the facility did not have documentation which indicated the transfer and discharge forms were provided in writing to Resident 53 and the resident's representative. On 4/25/25 at 12:06 p.m., the DNS provided the facility's policy,Transfer and Discharge undated, and indicated it was the policy…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 1 of 1 resident reviewed for hospitalization. (Resident 53) Findings include: Resident 53's clinical record was reviewed on 4/23/25 at 2:15 p.m. The diagnoses included, but were not limited to, congestive heart failure and kidney failure. Resident 53's progress notes indicated the resident was sent to the hospital on 1/9/25 and 3/11/25. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy was provided to the resident or the resident representative. During an interview on 4/24/25 at 12:11 p.m., the Director of Nursing Services (DNS) indicated the facility did not have documentation which indicated the bed-hold forms were provided in writing to Resident 53 or the resident's representative. On 4/25/25 at 1:07 p.m., the Administrator provided the facility's policy,Bed Hold Notice undated, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plan fall interventions were in place for a resident who was at risk for falls for 1 of 4 residents reviewed for accidents. (Resident 107) Findings include: On 4/21/25 at 11:37 a.m., Resident 107 was observed to be resting in his bed. The bed was against the wall with no mat observed to be beside his bed. On 4/22/25 at 10:32 a.m., Resident 107 was observed to be resting in his bed. The bed was against the wall with no mat observed to be beside his bed. On 4/23/25 at 2:04 p.m., Resident 107 was observed to be resting in his bed. The bed was against the wall with no mat observed to be beside his bed. On 4/24/25 at 11:20 a.m., Resident 107's clinical record was reviewed. The diagnoses included, but were not limited to, traumatic brain injury, major depressive disorder, muscle weakness, anxiety, glaucoma, and dementia. The quarterly MDS (Minimum Data Set), dated 3/31/25, indicated Resident 107 had moderate cognitive impairment and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide care per the plan of care for 1 of 5 residents reviewed for unnecessary medications. Insulin was not held per physician's orders. (Resident 107) Findings include: On 4/24/25 at 11:20 a.m., Resident 107's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, traumatic brain injury, and dementia. The April 2025 Medication Administration Record (MAR) indicated to inject Humalog (insulin) 3 units subcutaneoulsy (under the skin) before meals. Hold if the blood sugar is less than 150 mg/dl (milligrams per deciliter), ordered 3/21/25. The MAR indicated the following: - On 4/5/25 before breakfast, the Humalog 3 units were administered. The blood sugar was 128 which was less than 150. The clinical record lacked documentation the insulin was held. - On 4/5/25 before lunch, the Humalog 3 units were administered. The blood sugar was 121 which was less than 150. The clinical record lacked documentation the insulin was held. - On 4/5/25 before dinner, the Humalog 3 units were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-27 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a licensed practical nurse observed medication administration for a resident who did not self administer medications for 1 of 1 resident observed during a random observation. (Resident B) Findings include: During an interview with Resident B on 1/27/25 at 9:40 a.m., a medication cup with eight different medications was observed on the bedside table. The medication cup contained a mixture of tablets and capsules. Resident B indicated there had been ten different medications in the cup however, he had taken two already. Resident B indicated staff did not typically observe him when taking medications. During an interview with LPN 1 on 1/27/25 at 9:42 a.m., LPN 1 indicated she had observed Resident B take all his medications that morning and was unsure where the medications in the cup had come from. During an interview with LPN 1 on 1/27/25 at 11:35 a.m., LPN 1 indicated Resident B's morning medications included eleven different medications. He was currently out of one of his medications therefore, she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure staff accurately documented wound care treatments for 1 of 3 residents reviewed for documentation. (Resident C) Findings include: Resident C's clinical record was reviewed on 1/27/25 at 2:05 p.m. The diagnoses included, but were not limited to, pressure ulcer and osteorarthritis of the knee. Current physician orders, dated 1/27/25, indicated Resident C's treatments included, but were not limited to: Left lateral foot: cleanse with wound cleaners, apply collagen to wound bed and cover with bordered gauze dressing once daily and prn (as needed). Left lateral lower leg: cleanse with wound cleanser, apply collagen to wound bed and cover with bordered gauze dressing once daily and prn. Right medial ankle: cleanse with wound cleanser, apply xeroform cover with bordered gauze, change daily. The clinical record lacked documentation which indicated the above treatments had been completed on 1/3/25, 1/6/25, 1/15/25, 1/17/25, 1/21/25, 1/24/25 and 1/25/25, nor had the resident refused the treatments on those dates. During an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 3 residents reviewed for abuse. (LPN 1, Resident C) Findings include: On 10/17/24 at 12:07 p.m., Resident C's clinical record was reviewed. The diagnosis included, but was not limited to, discitis (inflammation that develops between the intervertebral discs of the spine). Physician orders, dated 9/29/24, indicated Resident C's medications included, but were not limited to meropenem (an antibiotic) intravenous (IV) solution reconstituted 1 gm (gram) intravenously every 8 hours for discitis. The admission Minimum Data Set (MDS) assessment, dated 8/15/24, indicated Resident C had no cognitive impairment. During a phone interview on 10/17/24 at 2:36 p.m., Resident C indicated he had a PICC line (a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) inserted and received an IV medication each evening which took about 30 minutes to infuse. He had had trouble with LPN 1 in the past…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2024-06-24 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a self medication administration assessment was complete for residents with medications left at bedside for 1 of 1 random observations. (Resident 80) Findings include: On at 6/19/24 at 9:50 a.m., Resident 80 was observed in her room lying in bed next to the bedside table. On the bedside table in a plastic medication cup were 2 tablets of medication identified as 800 mg (milligrams) each of Sevelamer HCL (a medication used for persons on dialysis to lower blood phosphate levels). No facility staff members were present in the room at that time. Resident 80 indicated she took the medication with food, but she did not eat that morning, and the nurse left the medication on her bedside table and left the room. During an interview on 6/19/24 at 9:55 a.m., the Director of Nursing indicated the medication should not have been left with the resident, as medication administration was to be observed by the administering qualified staff unless the resident was assessed to be able to self administer medications. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 9 citations
  • Potential for harm · Dcited before2024-06-24 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 2 of 3 residents reviewed for hospitalization. (Resident 54 and Resident 64) Findings include: 1. Residents 54's clinical record was reviewed on 6/24/24 at 9:55 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and chronic kidney disease. Resident 54's progress notes indicated the resident was sent to the hospital on 1/27/24 and 2/15/24. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident and the resident representative. 2. Resident 64's clinical record was reviewed on 6/24/24 at 9:45 a.m. The diagnoses included, but were not limited to, type II diabetes mellitus and chronic kidney disease. Resident 64's progress notes indicated the resident was sent to the hospital on 6/17/24. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-24 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 2 of 3 residents reviewed for hospitalization. (Resident 54 and Resident 64) Findings include: 1. Residents 54's clinical record was reviewed on 6/24/24 at 9:55 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and chronic kidney disease. Resident 54's progress notes indicated the resident was sent to the hospital on 1/27/24 and 2/15/24. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy having been provided to the resident or the resident representative. 2. Resident 64's clinical record was reviewed on 6/24/24 at 9:45 a.m. The diagnoses included, but were not limited to, type II diabetes mellitus and chronic kidney disease. Resident 64's progress notes indicated the resident was sent to the hospital on 6/17/24. The clinical record lacked…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-24 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to have an ongoing communication with the dialysis center regarding dialysis care while at dialysis for 1 of 1 residents reviewed for dialysis care. (Resident 63) Findings include: On 6/20/24 at 10:13 a.m., Resident 63's clinical record was reviewed. The diagnoses included, but were not limited to end stage renal disease, hypertension, and dementia. The physician orders, dated 6/24/24 indicated the following: - Dialysis treatment on Monday, Wednesday, and Friday (start date 11/3/23). - Monitor Post Dialysis dressing for bleeding every Monday, Wednesday, and Friday (start date 7/28/23). - Post Dialysis Assessment every Monday, Wednesday, and Friday (start date 7/28/23). - Pre Dialysis Assessment every shift (start date 7/28/23). - Send Dialysis Communication Binder with resident to dialysis on Monday, Wednesday, and Friday (start date 7/31/23). A care plan, dated 7/28/23, indicated Resident 63 received hemodialysis due to end stage renal disease. The care plan lacked any documentation of dialysis facility communicating with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-24 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure medications were administered with adequate indications for use for 1 of 5 residents reviewed for unnecessary medications. Medications were administered outside of physician order parameters. (Resident 88) Findings include: On 6/21/24 at 11:38 a.m., Resident 88's clinical record was reviewed. The diagnoses included, but were not limited to, congestive heart failure, hypertension, and dementia. Resident 88's physician orders dated 6/24/24 indicated the following: - Lisinopril (medication used to treat high blood pressure) 20 milligrams (mg) by mouth one time a day for hypertension. Hold medication if the systolic blood pressure was less than 90 or diastolic blood pressure less than 60. If systolic blood pressure was greater than 160 and diastolic blood pressure was greater than 90, administer the medication and notify the MD. Recheck blood pressure in 30 minutes and document blood pressure (start date 4/18/24). - Metoprolol succinate extended release (medication used to treat high blood pressure) 25 mg by mouth one a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-24 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure staff documented neurological assessments for 1 of 1 residents reviewed for falls. (Resident 105) Findings include: On 6/24/24 at 10:18 a.m., Resident 105's clinical record was reviewed. The diagnoses included, but were not limited to, morbid (severe) obesity, abnormalities of gait and mobility, and edema. Progress notes indicated the following: - On 4/20/24 at 11:10 a.m., the resident was transferring self with a walker to his wheelchair and stepped on barbell weights instead of the floor. The resident complained of left knee pain and a 6 centimeter (cm) by 0.5 cm abrasion was assessed on his left knee. - On 4/20/24 at 2:06 p.m., a telehealth note indicated the resident was found on the floor. He did not know his bed was elevated when he tried to get up and lost his balance. The resident complained of left knee pain, but refused treatment. - On 4/20/24 at 2:30 p.m., the resident was playing game system. The author indicated neuro checks continue and were within normal limits. No documentation was noted in regard to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to prevent a fall when staff did not use a gait belt (an assistive device used by staff that wraps around a resident to assist the resident and staff with a transfer) to transfer a resident who was dependent on staff for transfers for 1 of 3 residents reviewed for falls. (Resident B) Finding included: During an interview on 4/2/24 at 9:37 a.m., Resident B indicated she had more than one fall. Resident B thought she had a fall when she took a shower. During an interview on 4/2/24 at 11:22 a.m., CNA 1 (Certified Nursing Aide) indicated CNA 1 and CNA 2 took Resident B to the shower room. When CNA 1 and CNA 2 attempted to transfer Resident B, Resident B's knee went out and CNA 1 and CNA 2 lowered Resident B to the floor. Neither CNA 1 nor CNA 2 used a gait belt to assist Resident B transfer from a wheelchair to the shower chair. CNA 1 should have used a gait belt During an interview on 4/2/24 at 11:27 a.m., CNA 2 indicated CNA 2 and CNA 1 took Resident B to the shower room. CNA 2 and CNA 1 tried to transfer Resident B and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 3 of 3 kitchen observations. Food was stored beneath a water line on which water had condensed and the kitchen walk-in freezer door and walk-in refrigerator seal gasket was in disrepair. Findings include: 1. During a tour of the facility's walk-in freezer on 7/24/23 at 10:30 a.m., food was observed to be stored beneath the freezer condenser water line, upon which water had condensed and ice had formed. Beneath the freezer condenser was a box of dough and a large covered pan of lasagna covered in ice that originated from the condenser water line. During an interview on 7/24/23 at 10:35 a.m., the Dietary Manager indicated the food should not have been kept under the freezer condenser. 2. During tours of the kitchen walk-in freezer on 7/18/23 at 10:30 a.m. and 7/24/23 at 10:20 a.m., the following observations were made: the freezer door seal gasket was observed to be out of alignment and in misshaped condition, preventing a tight seal. The door required excessive…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-24 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the residents status for 2 of 3 residents reviewed for resident assessment. (Resident 34, Resident 36) Findings include: 1. On 7/24/23 at 10:40 a.m., Resident 34's clinical record was reviewed. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), other psychotic disorder, schizophrenia, anxiety, and major depressive disorder. An Annual MDS assessment, dated 12/19/22, indicated the resident was not evaluated by Level II Preadmission Screening and Resident Review (PASRR) and determined to have a serious mental illness. A Notice of PASRR Level II Outcome, dated 3/22/22, indicated based on the diagnoses, treatment history, current symptoms, and service needs, she met PASRR criteria. The Level II outcome indicated she was approved for long term care without specialized services. During an interview on 7/24/23 at 3:50 p.m., the MDS coordinator indicated the resident's MDS assessment was coded inaccurately because she had a Level II…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff implemented new weight loss interventions for a resident with an assessed weight loss for 1 of 7 residents reviewed for nutrition. (Resident 3) Finding includes: On 7/21/23 at 1:05 p.m., Resident 3 was observed to be sitting in her chair in her room eating a ham and cheese sandwich. At that time, Resident 3 indicated she did not want what was served for lunch, and she wanted a ham and cheese sandwich. On 7/21/23 at 11:07 a.m., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, osteoporosis, mood disorder, and anxiety. The quarterly Minimum Data Set (MDS) assessment, dated 7/3/23, indicated Resident 3 was cognitively intact, required supervision with eating, and had a 5% weight loss in the last month or a 10% weight loss in the last 6 months. The Care Plans incuded, but were not limited to, At risk altered nutrition/hydration. Resident has a history of significant weight loss and declining meals. Has a need for supplements to meet estimated needs. Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$9,249 in federal fines across 1 penalty.

  • $9,249 — penalty dated 2025-04-03

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to BRICKYARD HEALTHCARE — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.7-1.7 vs chain
Health inspection 1 of 52.3-1.3 vs chain
Staffing 1 of 52.4-1.4 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 22 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Brickyard Healthcare - Elkhart Care CenterElkhart, IN 1 of 5Brickyard Healthcare - Golden Rule Care CenterRichmond, IN 1 of 5Brickyard Healthcare - Merrillville Care CenterMerrillville, IN 1 of 5Brickyard Healthcare - Richmond Care CenterRichmond, IN 2 of 5Brickyard Healthcare - Brandywine Care CenterGreenfield, IN 2 of 5Brickyard Healthcare - Fountainview Care CenterMishawaka, IN 2 of 5Brickyard Healthcare - Laporte Care CenterLa Porte, IN 2 of 5Brickyard Healthcare - Portage Care CenterPortage, IN 2 of 5Brickyard Healthcare - Terrace Care CenterLa Porte, IN 2 of 5Brickyard Healthcare - Twelfth Street Care CenterMishawaka, IN 2 of 5Brickyard Healthcare - Willow Springs Care CenterIndianapolis, IN 3 of 5Brickyard Healthcare - Brookview Care CenterIndianapolis, IN 3 of 5Brickyard Healthcare - Muncie Care CenterMuncie, IN 3 of 5Brickyard Healthcare - Woodbridge Care CenterEvansville, IN 3 of 5Brickyard Healthcare -Sycamore Village Care CenterKokomo, IN 4 of 5Brickyard Healthcare - Churchman Care CenterIndianapolis, IN 4 of 5Brickyard Healthcare - Lincoln Hills Care CenterTell City, IN 4 of 5Brickyard Healthcare - Petersburg Care CenterPetersburg, IN 4 of 5Brickyard Healthcare - Valparaiso Care CenterValparaiso, IN 4 of 5Brickyard Healthcare - Woodlands Care CenterNewburgh, IN 5 of 5Brickyard Healthcare - Brentwood Care CenterEvansville, IN 5 of 5Brickyard Healthcare - Knox Care CenterKnox, IN

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
SWABY, SCOTTIndividualCONTRACTED MANAGING EMPLOYEEsince 02/22/2021
ENGELS, ERINIndividualCORPORATE DIRECTORsince 10/25/2014
GENTRY, MARKIndividualCORPORATE DIRECTORsince 01/12/2022
STARKEY, TYLERIndividualCORPORATE DIRECTORsince 08/01/2020
WAITE, JOHNIndividualCORPORATE DIRECTORsince 08/01/2020
WHICKER, TIMOTHYIndividualCORPORATE DIRECTORsince 01/12/2022
FENOUGHTY, DEANNAIndividualCORPORATE OFFICERsince 07/10/2023
GGNSC BLOOMINGTON LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2012

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$16.2M
Net patient revenuemost recent cost report
+13.6%
Operating marginrevenue minus expenses
$732K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 82%Medicare 5%Other / private 13%

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $732K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$325per resident / day
operating cost
$9,873per month
≈ monthly operating cost
$376per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155278. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next