Brickyard Healthcare - Muncie Care Center

In the surveyor’s words

From the most serious findings on record at Brickyard Healthcare - Muncie Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 3, 2023

  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. […]

• Actual harm, isolatedF607Aug 3, 2023

  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. […]

• Actual harm, isolatedF600Feb 28, 2023

  Based on interview and record review, the facility failed to prevent the physical abuse of a cognitively impaired resident (Resident G) by a staff member (CNA [Certified Nursing Aide] 17). The facility also failed to prevent sexually inappropriate behaviors when a cognitively intact resident (Resident F) touched a severely cognitively impaired resident (Resident E) inappropriately. Using the reasonable person concept, it is likely these deficient practices would lead to chronic or recurrent fear and anxiety. The deficient practice was corrected by February 15, 2023, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments, audits, and education related to abuse. Findings include: 1. […]

• Actual harm, isolatedF689Oct 6, 2021

  Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent and provide adequate assessment of a fall for 1 of 4 residents reviewed for accidents (Resident B) This deficient practice resulted in Resident B sustaining a fracture of the left ankle. Findings include: The clinical record for Resident B was reviewed on 10/5/2021 at 9:38 a.m. Diagnoses included, but were not limited to, [CONDITION(S)], hypertension, left eye [CONDITION(S)], chronic pain syndrome and depression. The last documented weight of the resident was on 7/25/2021 at 307 pounds. An Admission Minimum Data Set (MDS) assessment, dated 6/24/201, indicated the resident was severely cognitively impaired. […]

• Actual harm, isolatedF690Sep 15, 2021

  Based on interview and record review, the facility failed to ensure monitoring for a resident's suprapubic catheter for 1 of 3 residents reviewed for urinary infections (Resident E). This deficient practice resulted in Resident E being admitted to the hospital for [CONDITION(S)] and a UTI (Urinary Track Infection). Findings include: Resident E's clinical record was reviewed on 9/14/21 at 10:13 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His medications and orders included, but were not limited to, [MEDICATION(S)] (decrease [MEDICATION(S)] levels) solution 30 cubic centimeter (cc) daily, [MEDICATION(S)] (bladder relaxant) 5 (mg) milligram daily, tamsulosin (treat urinary retention) 0.4 mg daily, change catheter bag and leg bag on the first and the 15th on night shift, cleanse… […]