Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brickyard Healthcare - Bloomington Care Center during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, seizure disorder, and psychotic disorder, and with a history of wandering and elopement, left the facility property without staff knowledge after being last seen going to smoke. Staff later found him off-site after he had walked away from the building. Surveyors also observed the secured unit courtyard gate latched but not locked and easily opened, with access to other sidewalks and areas around the facility property.
A resident with hemiplegia, dementia, and aphasia was found with a sock and elastic band restraining his left hand, applied by a CNA without a physician's order, consent, or documentation. The restraint was used after repeated episodes of fecal smearing, and the care plan did not address such interventions. The incident resulted in swelling and injury to the resident's hand, and the facility's policy prohibiting unauthorized restraints was not followed.
Surveyors observed persistent environmental deficiencies, including strong urine odors, stained substances around toilets and showers, damaged walls, missing closet doors, and sticky entry/exit doors in a secured unit and several resident rooms. Facility leadership acknowledged these issues, which were inconsistent with residents' rights to a clean, comfortable, and homelike environment.
A resident with a history of falls and multiple health conditions was not provided with a bed mat as required by their care plan, despite repeated observations showing its absence. Nursing staff were unaware of the intervention, and the facility's fall prevention policy was not followed, resulting in a failure to implement necessary fall prevention measures.
A resident with diabetes was administered Humalog insulin multiple times when blood sugar readings were below the physician-ordered threshold, contrary to the care plan and facility policy. Documentation did not show that the insulin was held as required, and the DON confirmed the medication was given outside the prescribed parameters.
A cognitively impaired resident with a history of exit-seeking behavior and an appointed guardian was able to leave the facility unsupervised and was found by law enforcement nearly two miles away. The resident had previously been moved from a secured to an unsecured unit without a required physician evaluation, and care plans and elopement risk assessments were not updated after multiple incidents of exit-seeking and agitation. Staff were unaware of the ongoing risk, and the lack of supervision and updated care planning led to the resident's elopement.
A facility failed to ensure proper medication administration for a resident who did not self-administer medications. During an observation, a medication cup with eight medications was found on a resident's bedside table, and the resident indicated that staff did not typically observe him taking medications. The clinical record lacked a self-medication administration assessment, and the facility's policy required licensed nurses to observe medication consumption.
A facility failed to document wound care treatments for a resident with a pressure ulcer and osteoarthritis. The clinical record lacked documentation of completed treatments or refusals on several dates, as confirmed by the Interim DON. The facility's policy mandates documentation of all services provided, which was not followed in this instance.
A resident with discitis was verbally abused by an LPN after requesting assistance with IV tubing. The resident and LPN exchanged profanities, with the LPN following the resident down the hall while continuing to use expletives. The incident was witnessed by another LPN, who intervened and reported the situation to the nursing manager.
A resident was found with Sevelamer HCL tablets left at their bedside without a completed self-medication assessment. The resident, who was cognitively intact, had not eaten that morning, which was necessary for taking the medication. The DON confirmed that medication should not have been left with the resident without an assessment.
The facility failed to provide the required written transfer and discharge notices to two residents and their representatives. One resident with chronic conditions was sent to the hospital twice without documentation of the notice, and another resident with diabetes and kidney disease was also transferred without the necessary written notice. The DON confirmed the oversight, which contradicts the facility's policy.
The facility failed to provide written notification of its bed-hold policy to two residents or their representatives upon hospital transfer. The clinical records for these residents, who had chronic conditions, lacked documentation of the required notification. The DNS confirmed that the facility did not provide the forms in writing, contrary to the facility's policy.
A facility failed to maintain communication with a dialysis center for a resident with end-stage renal disease, resulting in incomplete documentation of dialysis care. Despite physician orders for regular dialysis and assessments, communication forms remained blank, indicating a lack of collaboration as required by facility policy.
A resident with hypertension was administered Lisinopril and Metoprolol despite vital signs indicating the medications should have been held, as per physician orders. The facility's records lacked documentation of holding the medications, leading to a deficiency in medication administration practices.
A resident with morbid obesity and mobility issues experienced two falls in one day, resulting in knee pain and an abrasion. Despite notes indicating ongoing neuro checks, the facility failed to document these assessments at required intervals. The DON acknowledged gaps in documentation due to inconsistent use of a new neuro check flowsheet.
The facility failed to prevent a fall when staff did not use a gait belt to transfer a resident dependent on staff for transfers. The resident, with multiple diagnoses including multiple sclerosis, was lowered to the floor by two CNAs after her knee gave out during a transfer to the shower chair. The DON confirmed that a gait belt should have been used.
Failure to Supervise Exit-Seeking Resident and Secure Courtyard Gate
Penalty
Summary
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. The resident had diagnoses including dementia, seizure disorder, and psychotic disorder, and was identified in prior records as at risk for wandering and elopement due to a history of attempting to leave the facility and impaired safety awareness. On the morning of the incident, staff last saw the resident going to smoke, but he was later found off the property after leaving the facility unnoticed and walking to a location nearly a mile away. Staff interviews showed that the resident was not with the group being supervised during smoke time, and the Activity Assistant stated she had not seen him outside during that period. The Administrator reported seeing the resident’s walker outside near the main entrance and then initiating a search after not seeing the resident. The resident was later located at a carwash approximately 0.7 miles from the facility and returned with the Administrator. The resident stated he had been trying to go to the store to buy cigarettes and planned to return. The facility also failed to ensure the secured unit courtyard gate was locked during observations of the enclosed courtyard. Surveyors observed the gate latched but not locked and easily opened, with access leading to additional sidewalks, another gate, grassy areas, and paths around the facility property. The Maintenance Manager stated the gate should have been locked and believed it had been left unlocked by the lawn crew. The resident also stated he had left the facility through the secured unit courtyard gate to walk to the store.
Resident Restrained Without Order or Documentation
Penalty
Summary
A resident with hemiplegia, dementia, and aphasia was found to have a sock tied around his left hand, which was later discovered to be secured with an elastic waistband from underwear. This restraint was applied by a CNA without a physician's order, consent, or documentation. The resident's care plan did not include interventions for the use of a glove or sock to address his behavior of smearing feces, and there was no documentation in the clinical record regarding the use or release of the restraint. The incident was reported after the resident was found with swelling, red and purple areas, and linear indentations on his left hand and wrist, indicating injury from the restraint. Interviews revealed that the CNA applied the sock and elastic band after repeated episodes of the resident smearing feces and being unable to obtain a glove from nursing staff. The CNA did not inform the next shift about the restraint. The facility's policy states that residents have the right to be free from physical restraints used for staff convenience or discipline, and the restraint was not ordered or documented as required. The lack of appropriate assessment, documentation, and adherence to policy led to the resident being restrained without proper authorization or monitoring.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, staff, and the public in one of its secured units and in five of seven resident rooms reviewed. Multiple observations over several days revealed persistent issues, including strong urine odors and brown stained substances around toilets and shower room stalls, damaged drywall and wallboard, holes in walls, protruding nails and screws, missing closet doors, and sticky entry/exit doors. These environmental deficiencies were noted in both common areas and individual resident rooms, affecting the overall condition and comfort of the living spaces. Interviews with facility leadership confirmed awareness of these issues, and a review of the facility's Residents Rights documentation indicated that residents are entitled to a safe, clean, comfortable, and homelike environment. The presence of these environmental concerns demonstrates a failure to uphold these rights, as the conditions observed were not in line with the standards outlined in the facility's own policies.
Failure to Implement Care Plan Fall Interventions for At-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with a history of falls and multiple diagnoses, including traumatic brain injury, muscle weakness, and dementia, was not provided with a fall intervention as specified in their care plan. The care plan, updated to include a bed mat as a fall prevention measure, was not implemented, as the resident was repeatedly observed without a mat beside the bed over several days. The resident's clinical record indicated moderate cognitive impairment and a recent history of two or more falls without injury. Interviews with nursing staff revealed a lack of awareness regarding the required fall intervention, with one LPN unsure if a mat was needed and not referencing the care plan or Kardex for guidance. The Director of Nursing Services confirmed that fall interventions should be accessible in the care plan or Kardex. The facility's fall prevention policy required additional interventions based on assessment, but the specified intervention of a bed mat was not in place for the resident at risk.
Failure to Hold Insulin per Physician Order for Blood Sugar Parameters
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes mellitus, traumatic brain injury, and dementia was not provided care according to the physician's orders and the established plan of care. The physician's order specified that Humalog insulin, 3 units subcutaneously before meals, should be held if the resident's blood sugar was less than 150 mg/dl. Despite this, the Medication Administration Record (MAR) documented multiple instances where the insulin was administered even though the resident's blood sugar was below the specified threshold. There was no documentation indicating that the insulin was held as ordered on these occasions. The care plan for the resident included an intervention to administer diabetes medication as ordered by the physician. The facility's policy on medication administration also required medications to be held if vital signs were outside the physician's prescribed parameters. During interviews, the Director of Nursing Services confirmed that the resident received Humalog when blood sugar was less than 150 mg/dl, contrary to the physician's order. The clinical record lacked documentation to support that the medication was withheld as required.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of exit-seeking behavior and an appointed guardian was able to leave the facility without staff knowledge. The resident, who had diagnoses including major depressive disorder, dementia, cognitive communication deficit, and psychoactive substance abuse, was initially admitted to a secured unit due to elopement risk but was later transferred to an unsecured unit. The transfer occurred without a documented physician's evaluation, as required by facility policy, and the resident's care plan and elopement risk assessments were not updated following multiple incidents of exit-seeking and agitation. Despite previous documented behaviors such as attempting to leave the facility, expressing a desire to go home, and being found outside unsupervised, the resident was assessed as not at risk for elopement in subsequent evaluations. The care plan interventions, including supervision and education on leave of absence policy, were not revised after the resident's transfer to the unsecured unit or after incidents indicating ongoing elopement risk. Staff interviews revealed a lack of awareness regarding the resident's continued exit-seeking behaviors and the absence of updated risk assessments and care planning. The deficiency resulted in the resident leaving the facility unobserved, being found by law enforcement 1.8 miles away on a busy road, and subsequently returned to the facility. The facility's failure to provide adequate supervision and update care plans and risk assessments in response to the resident's behaviors directly led to the elopement event.
Removal Plan
- audits of elopement evaluations and care plans
- inservicing staff on elopement procedures
- ongoing monitoring
Failure to Observe Medication Administration
Penalty
Summary
The facility failed to ensure proper medication administration for a resident who did not self-administer medications. During a random observation, a medication cup with eight different medications was found on Resident B's bedside table. Resident B mentioned that there had been ten medications in the cup, but he had already taken two. The resident indicated that staff did not typically observe him when taking medications. LPN 1 claimed to have observed Resident B take all his medications that morning and was unsure of the origin of the medications in the cup. However, the Interim Director of Nursing confirmed that Resident B did not self-administer medications and that medications should not have been left at the bedside. Resident B's clinical record indicated diagnoses of acute kidney failure and chronic obstructive pulmonary disease. The current physician orders included a list of medications that Resident B was supposed to take, but the clinical record lacked a self-medication administration assessment. The facility's policy on medication administration required licensed nurses to observe resident consumption of medication, which was not adhered to in this instance. This deficiency was related to complaints IN00450128 and IN00450202.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure accurate documentation of wound care treatments for a resident diagnosed with a pressure ulcer and osteoarthritis of the knee. The clinical record review revealed that the prescribed treatments for the resident's wounds on the left lateral foot, left lateral lower leg, and right medial ankle were not documented as completed on several specific dates. There was also no documentation indicating that the resident had refused these treatments on those dates. During an interview, the Interim Director of Nursing confirmed the absence of documentation for the treatments or refusals in the clinical record. The facility's policy requires licensed staff to document all services provided in the resident's medical record, but this was not adhered to in this case.
Resident Subjected to Verbal Abuse by LPN
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member. Resident C, who had no cognitive impairment and was receiving intravenous medication for discitis, reported an incident involving verbal abuse by LPN 1. On the morning of the incident, Resident C found himself entangled in IV tubing and sought assistance from LPN 1. When he asked her to remove the IV, LPN 1 responded dismissively, leading to an exchange of profanities between them. Resident C reported that LPN 1 followed him down the hall, continuing to use expletives. The incident was corroborated by statements from LPN 1 and LPN 2, who witnessed the exchange. LPN 1 admitted to exchanging profanities with Resident C, citing a difficult night as a contributing factor to her behavior. LPN 2 intervened by calming Resident C and notifying the nursing manager on call, who instructed LPN 1 to leave the facility pending investigation. The facility's policy on abuse, neglect, and exploitation defines verbal abuse as the use of disparaging and derogatory terms, which was violated in this incident.
Failure to Complete Self-Medication Assessment
Penalty
Summary
The facility failed to ensure a self-medication administration assessment was completed for a resident who had medications left at their bedside. During an observation, a resident was found lying in bed with two tablets of Sevelamer HCL, each 800 mg, on the bedside table. The resident indicated that the nurse left the medication there and left the room, and she had not eaten that morning, which was necessary for taking the medication. The Director of Nursing confirmed that medication administration should be observed by qualified staff unless the resident is assessed to self-administer medications. A review of the resident's clinical record showed no self-medication administration assessment, despite the resident being cognitively intact and having a physician's order for the medication to be taken with meals.
Failure to Provide Written Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide the required written notification for transfer and discharge to two residents and their representatives. Resident 54, diagnosed with chronic obstructive pulmonary disease and chronic kidney disease, was sent to the hospital on two occasions, but the clinical record lacked documentation of the written Notice of Transfer and Discharge forms being provided. Similarly, Resident 64, with type II diabetes mellitus and chronic kidney disease, was transferred to the hospital without the necessary written notice. During an interview, the Director of Nursing Services confirmed that the facility did not provide the written notices to the residents or their representatives, instead sending the forms with the residents upon transfer. The facility's policy mandates that the transfer/discharge notice be provided to both the resident and their representative.
Failure to Provide Written Bed-Hold Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required. This deficiency was identified for two residents, Resident 54 and Resident 64, during a review of their clinical records. Resident 54, who had diagnoses including chronic obstructive pulmonary disease and chronic kidney disease, was transferred to the hospital on two occasions, but the clinical record lacked documentation of the required written notification. Similarly, Resident 64, with diagnoses including type II diabetes mellitus and chronic kidney disease, was transferred to the hospital, and the clinical record also lacked the necessary documentation of written notification. During an interview, the Director of Nursing Services (DNS) confirmed that the facility did not provide the bed-hold notification forms in writing to the residents or their representatives. Instead, the forms were sent with the residents when they were transferred to another facility. The facility's policy, which was undated but currently in use, stated that written notice specifying the duration of the bed-hold policy should be provided at the time of transfer for hospitalization or therapeutic leave. This failure to adhere to the policy resulted in the identified deficiency.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis center for a resident requiring dialysis care. Resident 63, diagnosed with end-stage renal disease, hypertension, and dementia, had physician orders for dialysis treatment three times a week and assessments before and after dialysis sessions. Despite these orders, the facility's records, including the care plan and various communication forms, lacked documentation of communication from the dialysis center. This absence of documentation was noted on multiple dates, indicating a consistent failure to record necessary information from the dialysis center. Interviews with the Assistant Director of Nursing Services (ADNS) revealed that although the resident was sent to the dialysis center with a communication binder, the dialysis center did not fill out the required information. The facility's policy on hemodialysis, which emphasizes coordination and collaboration with the dialysis facility, was not adhered to, as evidenced by the blank communication forms upon the resident's return from dialysis. This lack of documentation and communication between the facility and the dialysis center constitutes a deficiency in providing appropriate dialysis care.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for a resident with diagnoses including congestive heart failure, hypertension, and dementia. The resident was prescribed Lisinopril and Metoprolol for hypertension, with specific instructions to hold the medications if the systolic blood pressure was less than 90, diastolic blood pressure was less than 60, or if the pulse was less than 60 for Metoprolol. However, the medications were administered multiple times despite the resident's vital signs being outside the prescribed parameters. On several occasions in May and June 2024, the resident's diastolic blood pressure was recorded as less than 60, and the pulse was recorded as less than 60, yet the medications were still administered. The clinical records lacked documentation of the medications being held as per the physician's orders. This indicates a failure to adhere to the medication administration policy, which requires holding medications when vital signs fall outside the prescribed parameters. Interviews with the RN and the Director of Nursing Services confirmed that the medications were administered despite the resident's vital signs indicating they should have been held. The facility's policy on medication administration, which was reviewed, also emphasized the need to obtain and record vital signs and hold medications when necessary. The lack of documentation and adherence to physician orders led to the deficiency identified in the report.
Incomplete Neurological Assessment Documentation After Falls
Penalty
Summary
The facility failed to ensure proper documentation of neurological assessments for a resident who experienced falls. The resident, who had diagnoses including morbid obesity, gait abnormalities, and edema, was involved in two incidents on the same day. In the first incident, the resident stepped on barbell weights while transferring from a walker to a wheelchair, resulting in knee pain and an abrasion. Later, the resident was found on the floor after losing balance due to an elevated bed, again complaining of knee pain but refusing treatment. Despite notes indicating that neurological checks were ongoing and within normal limits, there was a lack of detailed documentation regarding the findings of these assessments. The neuro check documentation was incomplete, missing several required intervals post-fall. The Director of Nursing Services acknowledged the gaps in documentation, attributing them to the newness of the neuro check flowsheet and inconsistent use by nursing staff. The standard of care requires neuro checks for unwitnessed falls, which were not adequately documented in this case.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to prevent a fall when staff did not use a gait belt to transfer a resident who was dependent on staff for transfers. During an interview, Resident B indicated she had more than one fall and thought she had a fall when she took a shower. Certified Nursing Aides (CNA 1 and CNA 2) confirmed that they did not use a gait belt while transferring Resident B from a wheelchair to a shower chair, resulting in Resident B's knee giving out and her being lowered to the floor. The Director of Nursing (DON) confirmed that the staff should have used a gait belt during the transfer. Resident B's clinical record indicated diagnoses including multiple sclerosis, anxiety, and bipolar disorder, and a Quarterly Minimum Data Set (MDS) assessment showed that Resident B was moderately cognitively impaired and dependent on staff for chair-to-chair transfers. A Post Fall Evaluation documented that Resident B lost balance and was lowered to the floor by CNA 1 and CNA 2 in the shower room without the use of a gait belt. The facility's policy, provided by the DON, stated that gait belts should be used with residents who cannot independently ambulate or transfer for safety purposes.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 120 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bloomington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hearthstone Health Campus | 1.2 mi | ★★★★★ | 3 | 0 |
| Aperion Care Monroe | 1.4 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of Bloomington | 3.6 mi | ★★★★★ | 5 | 0 |
| Bell Trace Health And Living Center | 3.7 mi | ★★★★★ | 1 | 0 |
| Stonecroft Health Campus | 4.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.