Brickyard Healthcare - Muncie Care Center
2701 Lyn-Mar Dr, Muncie, IN 47304 · For profit - Corporation · 117 certified beds · (765) 286-5979 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has abuse, neglect, or exploitation citations (F0600, F0607) — most recent Jan 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- 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 (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 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
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 improved from 1 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.2% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.0% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 30.4% | 25.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.1% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 4.7% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.6% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.7% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.4% | 13.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.2% | 79.0% | 79.4% | 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.
42.4% 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 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 46% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.4%CMS range 26.5–58.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.6–13.7 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.1%CMS range 4.8–14.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 117 beds and averages 93.5 residents a day — about 80% occupied, or roughly 24 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 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 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 3.41 hrs/resident/day on weekends vs 3.90 on weekdays — 13% thinner on weekends. RN hours go from 0.90 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.
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
Deficiencies are more than at the previous inspection — worsening. 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.
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.
32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2023-08-03 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 of 4 residents reviewed for abuse (Resident B). Using the reasonable person concept, it is likely these deficient practices would lead to chronic or recurrent fear and anxiety. Findings include: During the initial tour of the AACU (Advanced Alzheimer's Care Unit) accompanied by LPN 27, on 8/2/23 at 9:45 a.m., Resident B was observed lying in her bed. LPN 27 indicated Resident B liked to take morning naps and wandered the unit in the afternoon. During an interview with LPN 27, on 8/2/23 at 11:28 a.m., she indicated Resident B was not aggressive but did have a tongue on her. It was typical to find her in someone else's room. On 8/2/23 at 2:13 p.m., Resident B was observed ambulating independently in the hallway. On 8/3/23 at 11:01 a.m., Resident B was observed sitting in a dining room chair at a table, with another resident across the table from her.…
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.
- Actual harm · G2023-08-03 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to report to the Administrator or designee allegations of abuse for 1 of 3 allegations of abuse reviewed (CNA 6 to Resident D). This failure to report the allegation immediately resulted in CNA 6's abuse of a cognitively impaired resident later in the day. Findings include: During an interview with LPN 19, on 8/2/23 at 4:39 p.m., she indicated CNA 7 had reported to her Resident D was grabbed roughly by CNA 6 during her shower on 7/29/23. LPN 19 was in the process of handling other things and was passing medication at the time CNA 7 reported this to her (between 8:00 a.m. and 9:00 a.m.). She did not report the allegation to the Administrator or their designee. An Incident Submission email confirmed an incident report was submitted to the Indiana Department of Health on 8/3/23 at 2:51 p.m. The actual or identified date and time of the incident was 7/31/23 at 1:39 p.m. The report indicated the following: The description added, on 8/3/23, indicated during another investigation, CNA 7 reported that Resident D alleged CNA 6 was…
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.
- Potential for harm · Dcited before2026-01-28 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 observation, record review, and interview, the facility failed to protect a resident's right to be free from abuse by failing to provide supervision to ensure a cognitively impaired resident who wandered (Resident B) was free from resident-to-resident physical abuse by a resident known to be aggressive towards others (Resident C) for 1 of 3 residents reviewed for abuse. The deficient practice was corrected on 1/26/26, prior to the start of survey, and was therefore past noncompliance. Findings include: Review of an Incident Report sent to the Indiana Department of Health indicated the following:On 1/18/26 at 6:53 p.m., Resident B and Resident C were in the dining room, following mealtime. Staff were assisting other residents to their rooms when they were alerted by yelling coming from the dining room. Resident B was on the ground and Resident C was kicking him. Resident C had a laceration to the lip and hematoma to the right side of the forehead. Action Taken, added 1/18/26, indicated both residents were immediately separated, the nurse called 911, and a head-to-toe…
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.
- Potential for harm · D2025-05-02 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the designated resident health care representative signed medical consent forms for 1 of 1 resident reviewed for health care representation. (Resident 256) Finding includes: Resident 256's clinical record was reviewed on 4/30/25 at 10:59 a.m. Diagnoses included schizoaffective disorder, bipolar disorder, and other cirrhosis of the liver. The admission date was 4/25/25. A 5/20/24 court document titled, Order Appointing Health Care Representative, indicated Resident 256 had been declared legally incompetent and appointed a legal health care representative. The health care representative was not related to Resident 256 and had full authority to make health care decisions. A 4/25/25 alert note indicated Resident 256's daughter told staff she was not the resident's health care representative. A voice mail message was left for the legal health care representative. A 4/26/25 mental health consent form was signed by Resident 256's daughter. A 4/26/25 psychotropic medications informed consent form was signed by 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.
- Potential for harm · D2025-05-02 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify the physician of elevated blood pressures for 1 of 5 residents reviewed for unnecessary medications. (Resident 39) Finding includes: Resident 39's record was reviewed on 4/29/25 at 2:21 p.m. Diagnoses included malignant neoplasm of frontal lobe, malignant neoplasm of parietal lobe, and essential (primary) hypertension. Current physician orders included, Aldactone (blood pressure medication) tablet 50 milligram (mg) one tablet by mouth one time a day, hydrochlorothiazide (blood pressure medication) 50 mg tablet by mouth in the morning, amlodipine besylate (blood pressure medication) 10 mg tablet give one tablet by mouth one time a day, and clonidine (blood pressure medication) 0.3 mg tablet give one tablet by mouth two times a day. An alert note dated 1/25/25 at 9:27 a.m. indicated the resident was admitted to the hospital for a stroke. Review of blood pressure readings from 4/1/25 through 5/1/25 indicated the following: 4/1/25 8:47 p.m. 200/90 mmHg (millimeters of mercury), 4/2/25 7:53 p.m. 200/101 mmHg, 4/9/25 8:48…
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.
- Potential for harm · D2025-05-02 · tag F0623 — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide notifications of hospitalization to the Long-Term Care Ombudsman for 1 of 3 residents reviewed for hospitalizations. (Resident 60) Finding includes: During an interview with Resident 60 on 4/28/25 at 1:44 p.m., he indicated he was hospitalized last month with pneumonia. Resident 60's record was reviewed on 5/1/25 at 11:19 a.m. Diagnoses included heart failure, end stage renal disease (kidney failure), dependence on renal dialysis, chronic obstructive pulmonary disease (COPD), and pneumonia. A progress note dated 3/12/25 at 10:18 p.m. indicated the resident was sent to the hospital by ambulance. A nurse's note dated 3/18/25 at 10:32 p.m. indicated the resident returned to the facility via ambulance at 6:00 p.m. During an interview with the SSD on 5/1/25 at 3:52 p.m., she indicated Ombudsman notifications for transfers and discharges had not been sent out for March 2025 and were usually sent within the first week of the next month. She was in…
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.
- Potential for harm · D2025-05-02 · tag F0625 — isolatedNotify 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 bed hold policies were provided to the resident and/or responsible parties at the time of the hospital transfer for 2 of 3 residents reviewed for hospitalization. (Residents 48 and 60) Findings include: 1. During an interview on 4/28/25 at 2:57 p.m., Resident 48 indicated she was hospitalized a couple months ago for about a week and did not receive any paperwork regarding a bed hold. Resident 48's record was reviewed on 4/29/25 at 2:37 p.m. Diagnoses included chronic respiratory failure, congestive heart failure, chronic obstructive pulmonary disease (COPD), centrilobular emphysema, asthma, and pneumonia. A progress note, dated 1/26/25 at 4:38 p.m., indicated the resident was sent to the hospital for difficulty breathing. A progress note, dated 1/31/25 at 6:40 p.m. indicated the resident returned from the hospital. The clinical record lacked indication of bed hold notification or policy was provided to the resident or representative. 2. During an interview with Resident 60 on 4/28/25 at 1:44 p.m., he indicated he…
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.
- Potential for harm · Dcited before2025-05-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 catheter care in a manner to reduce the risk of contamination for 1 of 1 resident reviewed for catheter services (Resident 46). Findings include: During an observation on 5/2/25 at 2:08 p.m., CNA 14 performed ABHR (alcohol based hang rub) prior to entry the resident's room. A PPE (personal protective equipment) cart was located just inside the door. CNA 14 donned gloves but no gown. She bent down and emptied resident 46's catheter bag into a plastic graduated cylinder. She emptied the cylinder in the toilet, then removed her gloves and donned a new set, which she pulled from the pocket of her scrubs. No hand hygiene was performed. She then filled two plastic buckets with soap and water, placed washcloths into them and placed the buckets on the resident's bed. The CNA then assisted the resident to stand at his walker, placing her gloved hands on his left arm and shirt, as well as the walker, resulting in contaminated gloves. Using her contaminated gloved hands, she pulled down his pants, removed his…
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.
- Potential for harm · D2025-05-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 record review and interview, the facility failed to follow Registered Dietician recommendations and notify the physician for a resident experiencing significant weight loss for 1 of 4 residents reviewed for nutrition. (Resident 42) Finding includes: Resident 42's clinical record was reviewed on 4/30/25 at 2:58 p.m. Diagnoses included essential hypertension, morbid severe obesity due to excess calories, and type 2 diabetes mellitus. An overweight/obesity care plan, initiated on 8/5/21, indicated the resident received a carbohydrate controlled regular textured diet, experienced 5.7 percent (%) weight loss in 30 days, and weight loss in 180 days. Interventions included the following: Diet as ordered (8/5/21) and monitor meal intakes (8/5/21). A current care plan, initiated on 12/28/24, indicated the resident had behaviors and would refuse to be weighed. A current order, initiated 2/28/25, indicated a regular texture consistent carbohydrate diet. Resident 42's meal consumption, for the last 30 days was reviewed and indicated the resident typically ate 76-100 % of her meals,…
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.
- Potential for harm · D2025-05-02 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 check placement and prevent contamination during site care for 1 of 2 residents reviewed for feeding tubes. (Resident 36) Finding includes: Resident 36's clinical record was reviewed on 4/30/25 at 8:27 a.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke), oropharyngeal phase dysphagia (difficulty swallowing), and unspecified protein-calorie malnutrition. Current orders included check placement of tube prior to medication administration, flush feeding tube with 80 milliliters (ml) of water every shift, and place a split drain sponge with antibiotic ointment for feeding tube maintenance every shift. A 2/13/25, annual, Minimum Data Set assessment indicated Resident 36 had severe cognitive impairment. The resident required moderate assistance with eating. He was dependent on staff for assistance with all other activities of daily living. Nutritional approaches included a mechanically altered diet and a feeding tube. A discontinued care plan, resolved on 4/2/25, indicated 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.
- Potential for harm · D2025-05-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 follow physician orders regarding oxygen flow rate and humidity for 1 of 2 residents reviewed for oxygen. (Resident 48) Finding includes: Random observations of Resident 48 indicated the following: During an observation on 4/28/25 at 2:57 p.m., Resident 48 was in her bed asleep with oxygen on via nasal cannula at five liters per minute. The humidity bottle attached to the oxygen concentrator was empty and dated 4/24. During an interview with the resident, she indicated she wore oxygen continuous at four liters per minute. She was unable to get out of bed and did not adjust the oxygen flow rate. On 4/29/25 at 9:00 a.m., the resident was asleep in bed with the oxygen on via nasal cannula at five liters per minute. The humidity bottle attached to the oxygen concentrator was empty and dated 4/24. Resident 48's clinical record was reviewed on 4/29/25 at 2:37 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia (low oxygen), chronic respiratory failure 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.
- Potential for harm · D2025-05-02 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 individualized interventions for dementia services to reduce or eliminate the need for psychoactive medications for 1 of 4 residents reviewed for dementia care. (Resident 29) Findings include: Resident 29's clinical record was reviewed on 4/29/25 at 2:56 p.m. Current diagnoses included dementia with agitation, diabetes mellitus, insomnia, major depressive disorder, generalized anxiety disorder, and delusional disorder. Current physician's orders included the following psychoactive medications: Risperdal 0.5 mg (an anti-psychotic medication) - one tablet- two times daily for delusional disorder (4/29/25), buspirone HCL 10 mg (an anti-anxiety medication)- one tablet-three times daily for anxiety (3/3/25), Klonopin 0.5 mg (an anti-anxiety medication)- one tablet daily at bedtime (3/5/25), Zoloft 125 mg (an anti-depressant medication)- one tablet daily for depression (10/25/2024), and Remeron 7.5 mg (an anti-depressant used as an appetite stimulant). A 3/20/25, quarterly, Minimum Data Set (MDS) assessment…
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.
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- Potential for harm · D2025-05-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure shift to shift narcotic reconciliation was completed for 5 of 6 carts reviewed for medication storage. (C Unit 2 hall cart, C Unit 1 hall cart, Advanced Acute Care Unit cart (AACU), Acute Care Unit (ACU) short hall cart, ACU long hall cart) Finding includes: 1. During a medication storage observation of the C Unit 1 hall cart, accompanied by LPN 3 on 5/1/25 at 11:41 a.m., the Controlled Drugs- Count Record was reviewed and the following dates lacked shift to shift reconciliation of controlled substances: In April 2025- 4/4/25 on evening shift, 4/18/25 on evening shift, 4/20/25 on day and night shifts. During an interview, at the time of the observation, LPN 3 indicated the narcotic count sheet was to be completed at the beginning of every shift. The medication count needed to be completed before the two nurses signed the form verifying the count was correct. 2. During a review of the C Unit 2 hall cart Controlled Drugs- Count Record, provided by Medical Records on 5/1/25 at 12:50 p.m., the following dates 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.
- Potential for harm · D2025-05-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 and interview, the facility failed to ensure insulin was dated after opening and discarded when expired for 1 of 3 medication carts reviewed. (ACU Medcart) Finding includes: During an observation on [DATE] at 10:48 a.m., the ACU Medcart was reviewed with LPN 13. A Lantus Subcutaneous Solution 100 unit/ml (insulin glargine) vial for resident 59 was opened and dated [DATE] and a HumaLOG Injection Solution 100 unit/ml (insulin lispro) vial was opened and undated. A Dulaglutide Subcutaneous Solution (to treat diabetes) Pen-injector 4.5 mg/0.5 ml for resident 12 was opened and undated. An Insulin NPH (neutral protamine [NAME] insulin) Suspension Pen-injector 100 unit/ml for resident 18 was opened and unlabeled. LPN 13 indicated insulin expired 30 days after opening and the pens and vials should have been labeled appropriately and the expired items thrown away. On [DATE] at 9:25 a.m. manufacturer recommendations for the Lantus, retrieved from https://products.sanofi.us/lantus/lantus.html indicated…
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.
- Potential for harm · D2025-05-02 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to offer and educate residents regarding Pneumococcal vaccines per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for infection control. (Resident 48) Finding includes: Resident 48's clinical record was reviewed on 4/29/25 at 2:37 p.m. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and dependence on supplemental oxygen. An admission Minimum Data Set (MDS) assessment, dated 2/3/25, indicated the resident was cognitively intact. Specialized services included continuous oxygen therapy. Review of the resident's vaccinations included the following: The resident had a historical administration of Pneumovax (pneumococcal) 23 on 3/5/20, prior to admission to the facility. A Pneumococcal Vaccine Consent Form, dated 7/7/23, indicated the resident was provided education and declined administration. The clinical record lacked additional offerings of the Pneumococcal vaccine since 2023. During an interview 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.
- Potential for harm · D2025-05-02 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide education regarding and failed to offer COVID-19 vaccines per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for infection control. (Resident 48) Finding includes: Resident 48's clinical record was reviewed on 4/29/25 at 2:37 p.m. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and dependence on supplemental oxygen. An admission Minimum Data Set (MDS) assessment, dated 2/3/25, indicated the resident was cognitively intact. A COVID-19 Vaccine Consent/Declination Form, dated 9/13/23, indicated the resident was provided education and declined administration. The declination indicated the following information, I understand that I can change my mind at any time and accept the COVID-19 vaccination at a later time and will receive current education at that time. The clinical record lacked any other offerings of the COVID-19 vaccine since 2023. During an interview on 5/1/25 at 11:37 a.m., 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.
- Potential for harm · Dcited before2025-02-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to follow physician ordered parameters for medication administration related to a blood pressure medication for 1 of 3 residents reviewed for quality of care. (Resident B) Findings include: Resident B's closed clinical record was reviewed on 2/5/25 at 9:55 a.m. Diagnoses included heart failure, hypertension, constipation, dementia, and schizoaffective disorder. She was transferred to an emergency department and discharged from the facility on 12/28/25. A signed physician's order, dated 10/15/24, indicated to give metoprolol succinate extended release (to treat high blood pressure) 25 mg (milligram), 1/2 tablet (12.5 mg) in the evening to treat heart failure. The order indicated to hold the medication for a systolic blood pressure (SBP) below 100 and heart rate (HR) less than 60 beats per minute (BPM). On 12/22/24 at 8:00 p.m., the resident's SBP was 110 and her HR was 62 BPM. The resident's electronic medication administration record for December 2024, indicated the medication was held. The record lacked indication of 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.
- Potential for harm · F2024-07-12 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to designate one or more individual(s) as the Infection Preventionist with qualifying training or certification. The facility did not have a currently certified Infection Preventionist for 2 of the 5 days of the survey, or prior since 2/5/24. This deficient practice had potential to affect 98 of 98 residents in the facility. Findings include: During an interview on 7/8/24 at 10:35 a.m., the Administrator indicated RN 12 was the Infection Preventionist. A review of the facility's Infection Control Surveillance Binder was completed on 7/12/24 at 10:43 a.m., and documentation indicated the information was completed by the ADON. During an interview on 7/12/24 at 11:45 a.m., the ADON indicated she was the infection preventionist and had been in that roll since January 2024. During an interview 7/12/24 at 12:46 p.m., the Administrator indicated the ADON had been acting Infection Preventionist for the facility. RN 12 had been promoted about two months ago and had not completed her certification as yet. RN 13, who had Infection…
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.
- Potential for harm · E2024-07-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 implement and utilize infection prevention and control practices related to contact isolation, enhanced barrier precautions (EBP), and diagnostic testing for 3 of 5 residents reviewed for infection control. (Resident's B, C, and 99) 1.During an observation on 7/10/24 at 11:04 a.m., Resident B's door had an EBP sign on the left side of the door and a contact isolation sign was on the right side of the resident's door. The personal protective equipment canister was just inside the resident's room beside the bathroom door. The contact isolation sign indicated everyone must clean their hands, put on a gown, and put on gloves before entering the room. During an observation on 7/10/24 at 11:32 a.m., LPN 8 performed hand hygiene and put on gloves as she entered the resident's contact isolation room. She walked to the resident's left side of the bed and her clothing brushed up against the bed linens with her unprotected clothing. Then she went around the foot of the bed and used a graduated measuring container 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.
- Potential for harm · E2024-07-12 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to implement an antibiotic stewardship program per facility policy. This had the potential to affect 98 or 98 residents residing in the facility. Findings include: A review of the facilities Infection Control Surveillance Binder was completed on 7/12/24 at 10:43 a.m., for the months of May and June 2024, and included the following: For June 2024, the binder contained an Infection Control Report completed by the ADON. It indicated the facility had 19 infections and 19 residents received antibiotics. The binder lacked documentation of resident names and infection types, or supporting documentation of treatment's provided or criteria for determining treatment. For May 2024, the binder contained an Infection Control Report completed by the ADON. It indicated the facility had 18 infections and 18 residents received antibiotics. The binder included 14 Revised McGeer Criteria for Infection Surveillance Checklist forms and three lab or xray results. The checklists lacked documentation regarding symptoms, criteria, or type of…
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.
- Potential for harm · D2024-07-12 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure completion of a Significant Change Minimum Set (MDS) assessment within 14 days of a determined status change for 2 of 5 residents reviewed for timely Significant Change assessments. (Residents 18 and 203) Findings include: 1. Resident 8's clinical record was reviewed on 7/10/24 at 3:12 p.m. Diagnosis included Chronic Obstructive Pulmonary Disorder (COPD), morbid obesity due to excess calories, and dependence on supplemental oxygen. A current physician order, dated 12/8/23, indicated admission to hospice services related to COPD. The annual MDS assessment, dated 12/11/23, indicated the resident utilized oxygen daily and received hospice services. A significant change MDS assessment was not completed. During an interview, on 7/11/24 at 10:58 a.m., the MDS Coordinator indicated she started her current position in April of 2024. She utilized the Resident Assessment Instrument (RAI) manual for overseeing the MDS department. Resident 18 required a Significant Change assessment with the new order for hospice services. 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.
- Potential for harm · D2024-07-12 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure timely completion of Quarterly Minimum Data Set (MDS) assessments every three months for 1 of 5 reviewed for timely assessment. (Residents 65) Findings include: Resident 65's clinical record was reviewed on 7/10/24 at 3:37 p.m. Current diagnosis included heart failure, paranoid schizophrenia, bipolar disorder, and anxiety disorder. The resident had a Quarterly MDS assessment, with the Assessment Reference Date (ARD) of 12/13/23 completed on 1/11/24. The assessment was completed 15 days late. The resident had a Quarterly MDS assessment, with the ARD of 9/12/23 which was completed on 9/27/23. The assessment was completed one day late. During an interview, on 7/11/24 at 10:58 a.m., the MDS Coordinator indicated she started her current role in April 2024 and utilized the Resident Assessment Instrument (RAI) manual for organizing the MDS position. She indicated the above listed assessments were completed late. Review of the current RAI manual, retrieved from…
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.
- Potential for harm · D2024-07-12 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure timely submission of Minimum Data Set (MDS) assessments for 1 of 5 resident reviewed for assessment submission. (Resident 65) Findings include: Resident 65's clinical record was reviewed on 7/10/24 at 3:37 p.m. Current diagnoses included heart failure, paranoid schizophrenia, bipolar disorder and anxiety disorder. The resident had a Quarterly MDS assessment with the Assessment Reference Date (ARD) of 5/6/24, completed on 5/13/24. The assessment was completed on time. The record lacked a transmission date. During an interview, on 7/11/24 at 10:58 a.m., the MDS Coordinator indicated she was not aware this assessment had not been transmitted. Upon reviewing the above assessment, she thought this could be an error in the program, as she could see the document was marked as not required for transmission. She would need to reach out to her consultant for direction. Review of the current the RAI manual, retrieved from https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, on 7/15/24 at 9:16 a.m.,…
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.
- Potential for harm · D2024-07-12 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 observation, interview and record review, the facility failed to monitor the amount of fluids consumed by 1 or 2 residents on fluid restrictions reviewed for dialysis. (Residents 30) Findings include: The clinical record for Resident 30 was reviewed on 7/10/24 at 10:23 a.m. Diagnoses included end stage renal disease (ESRD), heart failure, and dependence on renal dialysis. A quarterly MDS (Minimum Data Set) assessment, dated 3/4/24, indicated the resident had moderate cognitive impairment, and made themselves understood and understood others. A current, 10/23/24 physician's order indicated a 1500 milliliter (ml) fluid restriction, with 960 ml to be provided by dietary and 540 ml provided by nursing. During an observation on 7/11/24 at 9:44 a.m., Resident 30 was asleep in bed. Several Styrofoam cups containing fluid and two cans of soda were observed on the overbed table and bedside table. A current care plan, initiated 1/20/23, indicated the resident was at risk for alteration in hydration related to fluid restriction due to ESRD. Interventions included to maintain fluid…
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.
- Potential for harm · Dcited before2024-07-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 consistent interventions to maintain urinary drainage devices for 2 of 3 residents reviewed for urinary catheters. (Residents B and C). Findings include: 1. Resident B's clinical record was reviewed on 7/9/24 at 3:04 p.m. Diagnoses included, paraplegia, obstructive and reflux uropathy, malignant neoplasm of the bladder, and Methicillin-resistant Staphylococcus aureus (MRSA - bacteria resistant to treatment) infection. A current physician order, dated 7/3/24, included Bactrim (antibiotic) Double Strength (DS) - give 1 tablet by mouth twice daily related to a MRSA infection for 10 days. A current physician order, dated 3/9/23, included monitor urostomy site for signs/symptoms of infection every shift for urostomy monitoring. A current physician order, dated 3/9/23, included record urostomy output every shift for output monitoring. A current physician order, dated 3/9/23, included observe for signs/symptoms of urinary tract infection such as leaking or abdominal cramps every shift and notify 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.
- Potential for harm · D2023-08-03 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to report timely to the State Agency allegations of abuse for 3 of 3 allegations of abuse (CNA 6 and Resident B, CNA 6 and Resident D, and Resident E and Resident C) and failed to report accurate information regarding allegations of abuse for 1 of 3 allegations of abuse (CNA 6 and Resident B). Findings include: 1. Review of a handwritten statement signed by CNA 7 and dated 7/29/23 and provided in the facility's investigation binder, indicated she and CNA 6 walked into a male resident's room to put him in bed and when they walked in, Resident B was laying in his bed. CNA 6 proceeded to shake Resident B pretty hard and Resident B was yelling to stop. CNA 6 grabbed Resident B by one leg and one arm and Resident B started kicking to be put down and CNA 6 dropped Resident B on the floor. Resident B hit her head on a bed frame. A change of condition note, dated 7/29/23 at 1:09 p.m., indicated Resident B hit her head during a possible fall incident. She had a small bump on the top of the right side of her head and she reported 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.
- Potential for harm · E2023-05-23 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to resolve resident council concerns related to long call light wait times. Findings include: During record review on 5/18/23 at 10:29 a.m., the resident council record binder for the April 2023 meeting indicated resident discussion of the need for more CNAs and concerns regarding lengthy call light response times. During the Resident Council interview on 5/19/23 at 11:00 a.m., attendees indicated the average call light wait time to be 20-30 minutes, and wait times could be up to one hour. Those present indicated many had called family members and asked for help. Those relatives had then called the nurse's station to request assistance for their family member. This had been mentioned at previous meetings over the last several months. During the Resident Council interview, Resident 75 indicated staff advised the situation would be discussed with the management team and follow up would be communicated back to the Resident Council. This had not been done. Resident 40 indicated he experienced an avoidable incontinent episode due…
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.
- Potential for harm · Dcited before2023-05-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 sexual abuse when a resident with severe cognitive impairment (Resident 22) was groped and kissed by a cognitively intact resident (Resident 59) with known sexually aggressive behavior for 2 of 3 residents reviewed for mood and behaviors. Findings include: Review of a facility reportable incident, dated 5/13/23, indicated Resident 59 moved towards Resident 22 in the dining room. Resident 22 yelled no. A staff member who was present in the dining room attempted to intervene and Resident 59 touched Resident 22's breast. 1. Resident 59's clinical record was reviewed on 5/18/23 at 10:47 a.m. Diagnoses included, cerebral infarction, other sexual dysfunction not due to a substance or known physiological condition, and end stage renal disease. A current care plan, revised on 5/3/23, indicated the resident had behaviors such as kissing residents, holding hands, and inappropriate touching. Interventions included 15-minute monitoring (2/6/23) and separate from other residents as necessary…
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.
- Potential for harm · Dcited before2023-05-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 record review and interview, the facility failed to following physician's orders regarding medication administration parameters for acetaminophen for 1 of 14 residents observed for medication administration. (Resident 58) Findings include: Resident 58's clinical record was reviewed on 5/23/23 at 11:17 a.m. Diagnoses included chronic viral hepatitis C and chronic pain. Current physician's order, included the following: a. Acetaminophen 500 (to treat pain) mg (milligrams), one tablet every eight hours for pain. The order contained instruction not to exceed three grams (3000 mg) of acetaminophen in 24 hours from all sources (10/26/22). b. Excedrin Migraine (aspirin 250 mg, acetaminophen 250 mg, caffeine 65 mg) (to treat migraine headaches), two tablets every four hours as needed for headache (4/12/23). c. Percocet (oxycodone 10 mg, acetaminophen 325 mg) (to treat pain), one tablet every four hours as needed for right ankle and joint pain of the right foot (4/12/23). A review of the electronic medication…
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.
- Potential for harm · Dcited before2023-05-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 promptly obtained urinary catheter orders and utilized proper urinary catheter assessment and management techniques for 1 of 2 residents reviewed for a urinary catheter. (Resident 29) Finding includes: During an interview on 5/17/23 at 10:12 a.m., with Resident 29, his suprapubic urinary catheter drainage bag was hung on the right side of his bed. It was the size of a urinary catheter leg bag (typically used for ambulatory resident to conceal under their clothing). The drainage bag contained only a trace of urine in the bottom of the drainage tube. This had been a problem since 5/16/23, and he had discussed it with the CNAs when they came to empty his drainage bag. It was not uncommon for the urinary catheter to be clogged because he had a lot of calcium in his body. They had not flushed his suprapubic catheter, nor changed it, since it had stopped draining appropriately. They would not flush the suprapubic catheter. During an interview on 5/18/23 at 12:16 p.m., the resident indicated he was not…
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.
- Potential for harm · D2023-05-23 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and 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 develop and implement behavioral programming regarding sexually inappropriate behaviors for 1 of 3 residents reviewed for mood and behaviors. (Resident 59) Finding includes: Resident 59's clinical record was reviewed on 5/18/23 at 10:47 a.m. Diagnoses included, cerebral infarction , other sexual dysfunction not due to a substance or known physiological condition, and end stage renal disease. Current orders included the following: one on one supervision every shift related to other sexual dysfunction (5/13/23) and 15-minute monitoring every shift for inappropriate sexual behavior (5/13/23). The most recent significant change MDS assessment, dated 4/26/23, indicated the resident was cognitively intact. A current care plan, revised on 5/3/23, indicated the resident had behaviors such as kissing residents, holding hands, and inappropriate touching. Interventions included, 15-minute monitoring (2/6/23) and separate from other residents as necessary (4/1/22). A current care plan, initiated 5/18/23, indicated the 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.
- Potential for harm · D2023-05-23 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 prime insulin pens to ensure accurate dose administration for 2 of 14 residents observed for medication administration. There were 25 opportunities with 2 errors, resulting in a 8% medication administration error rate. (Residents 43 and 6) Findings include: During an observation of medication administration for Resident 43 on 5/18/23 at 10:48 a.m., LPN 11 was observed preparing an aspart insulin pen (to treat diabetes). After sanitizing her hands and the lip of the top of the pen, she applied a new needle onto the pen and dialed a dose of six units. She used an alcohol swab to prepare the resident's skin and administered the injection into the resident's abdomen. During an observation of medication administration for Resident 6 on 5/28/23 at 12:19 p.m., LPN 11 was observed preparing an aspart insulin pen. After sanitizing her hands and the lip of the top of the pen, she applied a new needle onto the pen and dialed a dose of two units. She used an alcohol swab to prepare the resident's skin and administered…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 3 of 5 | 2.4 | +0.6 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 22 homes this chain runs (chain average 2.7★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| PATEL, KAUSHIK | Individual | CONTRACTED MANAGING EMPLOYEE | since 03/26/2023 |
| ENGELS, ERIN | Individual | CORPORATE DIRECTOR | since 10/15/2014 |
| GENTRY, MARK | Individual | CORPORATE DIRECTOR | since 01/12/2022 |
| STARKEY, TYLER | Individual | CORPORATE DIRECTOR | since 08/01/2020 |
| WAITE, JOHN | Individual | CORPORATE DIRECTOR | since 08/01/2020 |
| WHICKER, TIMOTHY | Individual | CORPORATE DIRECTOR | since 01/12/2022 |
| FENOUGHTY, DEANNA | Individual | CORPORATE OFFICER | since 07/10/2023 |
| MUNCIE OPERATING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 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.
About 80% 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 $692K 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
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
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.
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 155687. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-02, 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.