Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 - Muncie Care Center during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering and behavioral issues was physically assaulted by another cognitively impaired resident known to be paranoid and aggressive toward others. Earlier that day, staff had observed verbal conflict and agitation between the two residents related to one resident’s fear that others were entering his room. Later in the evening, while staff were assisting other residents after a meal, yelling was heard and staff found one resident on the floor in a fetal position while the aggressive resident was cursing, kicking, and stomping on his head, back, and ribs. The victim sustained a forehead hematoma, facial abrasion, and red areas on his back, and reported pain, while the aggressor continued to attempt to hit and kick staff when they intervened.
A resident with a court-appointed legal health care representative was admitted with multiple diagnoses, including schizoaffective disorder and cirrhosis. Despite staff being aware that the resident's daughter was not the authorized representative, she was asked to sign medical consent forms while the legal representative was unavailable, resulting in consents being signed by an unauthorized individual.
A resident with a history of hypertension and recent stroke experienced multiple episodes of significantly elevated blood pressure over a month, but the physician was not notified as required. Nursing staff interviews revealed inconsistent practices and lack of a clear protocol for physician notification, despite facility policy mandating prompt notification for changes requiring intervention.
A CNA failed to follow proper infection control procedures during catheter care for a resident with an indwelling catheter, including not wearing a required gown, not performing hand hygiene between glove changes, and using contaminated gloves to handle both clean and soiled items. The resident had a history of urinary tract issues and required enhanced barrier precautions, but facility protocols were not followed during the observed care.
A resident with multiple chronic conditions experienced significant weight loss while on a carbohydrate-controlled diet. Despite repeated recommendations from the IDT to discontinue the carbohydrate control portion of the diet and notify the physician, there was no documentation of physician notification or diet change. The DON was unaware of the recommendations due to reliance on incomplete reports, and the facility's policy requiring physician notification for significant weight changes was not followed.
A resident with severe cognitive impairment and a feeding tube did not receive care according to facility policy when an LPN failed to check tube placement before flushing and did not maintain proper hand hygiene or glove changes during site care. Supplies were placed on an unprotected surface, and contaminated gloves were used to handle multiple items and apply ointments, resulting in breaches of infection control protocols.
A resident with chronic respiratory conditions was repeatedly given oxygen at a higher flow rate than ordered, and the humidification bottle was left empty despite orders for regular changes. Nursing staff did not notify the physician when the resident's oxygen needs changed, and documentation of these changes was lacking, contrary to facility policy and physician orders.
A resident with dementia and multiple mental health diagnoses was maintained on several psychoactive medications, despite documentation showing that most behavioral events were effectively managed with non-chemical interventions. The care plans were not updated to reflect these successful approaches or to identify resolved behavioral issues, and lacked assessment of behavior triggers and personalized interventions. Staff interviews confirmed the resident responded well to individualized, non-pharmacological strategies, but the facility did not consistently implement or document these in the care plan.
Surveyors found that shift-to-shift narcotic reconciliation was not consistently completed for five medication carts, with numerous missing signatures on Controlled Drugs-Count Records across multiple units and shifts. Interviews with nursing staff and the DON confirmed that the facility's policy requires two licensed nurses to verify and sign off on narcotic counts at each shift change, but this was not consistently documented as required.
Surveyors found that insulin vials and pen-injectors on a medication cart were not properly labeled with opening dates or resident information, and some were not discarded after expiration. An LPN confirmed that these items should have been labeled and disposed of according to facility policy and manufacturer recommendations, but this was not done.
A resident with chronic respiratory conditions and a history of Pneumovax 23 vaccination declined the Pneumococcal vaccine upon admission after receiving education. The facility did not re-offer the vaccine at later eligible intervals, as confirmed by interviews with the Infection Preventionist and DON, despite policy and CDC guidance requiring ongoing vaccine offerings and education.
A resident with chronic respiratory conditions, who was cognitively intact, declined the COVID-19 vaccine upon admission after receiving education. The facility did not re-offer the vaccine or provide updated education in accordance with CDC guidance, as confirmed by staff interviews and a review of the clinical record.
A facility failed to follow physician-ordered parameters for medication administration for a resident with heart failure and hypertension. Metoprolol was held without documented reason despite being within parameters, and hydralazine was administered when SBP was below the threshold. The DON confirmed medications should be administered per orders, and the facility's policy requires holding medications if vital signs fall outside prescribed parameters.
The facility failed to designate a qualified Infection Preventionist, as the ADON acted in the role without certification until recently, and the certified RN 13 had not been involved since early in the year. This deficiency potentially affected all 98 residents.
The facility failed to implement proper infection control practices for three residents, leading to deficiencies in contact isolation, enhanced barrier precautions, and diagnostic testing. An LPN entered rooms without wearing required gowns, and a resident with loose stools was not placed in contact isolation while awaiting C. diff test results. These lapses highlighted significant issues in infection control protocols.
The facility failed to implement its antibiotic stewardship program, affecting all 98 residents. The Infection Control Surveillance Binder for May and June 2024 lacked necessary documentation, such as resident names, infection types, and treatment criteria. The ADON, responsible for infection prevention, did not complete or review forms and did not confirm appropriate antibiotic use, contrary to the facility's policy.
Two residents with urinary catheters experienced inconsistent management of their urinary drainage devices, with bags not being emptied regularly, leading to overfilling and leakage. Observations and interviews revealed that staff failed to adhere to the facility's policy of emptying bags when half-full or every 3 to 6 hours, resulting in deficiencies in care.
The facility failed to complete Significant Change MDS assessments within 14 days for two residents admitted to hospice services. One resident with COPD and another with Alzheimer's Disease did not receive the required assessments following their hospice admissions. The MDS Coordinator acknowledged the oversight, noting the use of the RAI manual for guidance.
A facility failed to complete Quarterly MDS assessments on time for a resident with heart failure, paranoid schizophrenia, bipolar disorder, and anxiety disorder. The assessments were completed 15 days and one day late, respectively. The MDS Coordinator, new to the role, acknowledged the delays, which were not in compliance with the RAI manual's requirement for completion within 14 days after the ARD.
A facility failed to submit a resident's MDS assessment on time. The resident, with conditions like heart failure and schizophrenia, had a Quarterly MDS assessment completed on time but lacked a transmission date. The MDS Coordinator was unaware of the issue, suspecting a program error, and planned to consult for guidance. The RAI manual requires submission within 14 days of completion.
A resident with ESRD and heart failure on a fluid restriction was not properly monitored for fluid intake, despite physician orders and care plans. Observations showed excess fluids at the bedside, and staff interviews revealed a lack of awareness and documentation. The facility's policy on fluid restriction was not adhered to, leading to a deficiency in care.
Failure to Prevent Resident‑to‑Resident Physical Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident who wandered from resident‑to‑resident physical abuse by another resident known to be aggressive. Resident C had documented diagnoses of moderate vascular dementia with agitation, severe dementia with agitation, anxiety, and mood disorder, and was care planned as having the potential to be aggressive, with behaviors including arguing with other residents, verbal aggression, yelling, name calling, and physical aggression when he believed others were somewhere they should not be. His care plan identified that he could become agitated and aggressive if he thought other residents were near or entering his room, and interventions included one‑on‑one supervision while awake and 15‑minute checks while asleep, as well as early intervention and removal from distressing situations. Progress notes shortly before the incident documented that Resident C was very paranoid and aggressive during a psychiatric visit and that he remained preoccupied and worried about a particular male resident going into his room. Resident B, the victim of the abuse, had severe vascular dementia with agitation, major depressive disorder, difficulty walking, and lower back pain, and was assessed as severely cognitively impaired with wandering behavior and a need for supervision while walking. His care plans documented wandering and elopement risk, including wandering into other residents’ rooms, and multiple behavior problems such as physical and verbal aggression, putting himself on the floor, wandering around the unit, cursing staff, and throwing items. He was on 15‑minute checks and had a history of wandering into other residents’ rooms, including an incident where he wandered into another resident’s room to urinate. On the day of the altercation, earlier in the morning, Resident B and Resident C had a “cursing match” when Resident B was close to the room of another male resident, and Resident C became agitated, believing another resident was in his room. Staff redirected both residents, and no physical contact occurred at that time. Later that same day, after mealtime, Resident B and Resident C were in or near the dining room while staff were assisting other residents to their rooms. Staff then heard yelling or a commotion from the dining area or hallway. When staff entered the hallway, they observed Resident B on the floor in a fetal position with his hands over his head, and Resident C standing over him, cursing, kicking, and stomping on Resident B’s back, sides, ribs, and head. Multiple staff witnesses consistently described Resident C as stomping and kicking Resident B in the head and rib area, with Resident B grabbing his ribs. Resident B sustained a hematoma to the right forehead, an abrasion to the left side of his face, red areas on his back, and reported generalized pain rated five out of ten. The beginning of the altercation was unwitnessed. The DON later stated that Resident C was abusive to Resident B by stomping and hitting him and that the facility should have prevented the resident‑to‑resident abuse. The Administrator acknowledged that the facility had knowledge of agitation between Resident B and Resident C earlier in the day prior to the physical assault.
Failure to Obtain Proper Medical Consents from Legal Health Care Representative
Penalty
Summary
The facility failed to ensure that the designated legal health care representative signed medical consent forms for a resident who had been declared legally incompetent. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and cirrhosis of the liver, was admitted with a court order appointing a non-family member as the legal health care representative with full authority to make health care decisions. Despite this, the resident's daughter, who was not the legal health care representative, signed multiple consent forms, including mental health consent, psychotropic medication informed consent, and a POST form, after informing staff she was not the authorized representative. Facility staff were aware that the legal health care representative was unavailable due to being on vacation and made attempts to contact him, including leaving a voicemail and speaking with his appointed contact person. However, the necessary consent forms were not sent to the legal health care representative by email, and the daughter was asked to sign the forms in the interim. The facility did not obtain the required signatures from the court-appointed representative prior to executing medical consents.
Failure to Notify Physician of Elevated Blood Pressures
Penalty
Summary
The facility failed to notify the physician of multiple instances of elevated blood pressure readings for a resident with a history of malignant neoplasms and essential hypertension. The resident was prescribed several antihypertensive medications and had a recent hospital admission for a stroke. Blood pressure readings documented over a one-month period showed several significantly elevated values, including readings as high as 222/138 mmHg. Despite these abnormal findings, there was no documentation in the clinical record that the physician had been notified of these elevated blood pressures. Interviews with nursing staff revealed inconsistency and lack of clarity regarding when to notify the physician about abnormal blood pressure readings. One LPN stated there was no standard protocol for physician notification, while another indicated she would notify the physician for blood pressures over 140, although there was no specific order for this. The DON confirmed there was no standing protocol for physician notification of abnormal vital signs unless directly ordered by the physician, but acknowledged that the physician should have been notified for blood pressures outside the resident's baseline. The facility's policy required prompt physician notification for changes requiring intervention or alteration of treatment, but this was not followed in the resident's case.
Failure to Follow Proper Catheter Care and Infection Control Procedures
Penalty
Summary
A certified nursing assistant (CNA) failed to provide catheter care in a manner that reduced the risk of contamination for a resident with an indwelling catheter. During the observed care, the CNA donned gloves but did not wear a gown as required for enhanced barrier precautions. After emptying the resident's catheter bag and removing gloves, the CNA did not perform hand hygiene before donning a new pair of gloves, which were taken from her pocket. Throughout the catheter care process, the CNA repeatedly used the same pair of gloves to touch various contaminated surfaces, including the resident's clothing, walker, soiled brief, trash can, and privacy curtain, before and during the cleaning of the resident's genitalia and catheter tubing. The CNA also handled clean supplies and applied a new brief with the same contaminated gloves, only removing them and performing hand hygiene at the end of the procedure. The resident involved had a history of malignant neoplasm of the prostate, benign prostatic hyperplasia with urinary tract symptoms, a history of urinary tract infections, and schizophrenia. Physician orders required regular catheter care and monitoring for signs and symptoms of urinary tract infection. Facility policy and signage indicated that both gown and gloves were required for all interactions with residents on enhanced barrier precautions, especially those with indwelling medical devices. The CNA was unsure about the need for hand hygiene after glove removal and acknowledged forgetting to don a gown, which was confirmed as a requirement by the facility's infection preventionist.
Failure to Notify Physician and Implement Dietitian Recommendations for Significant Weight Loss
Penalty
Summary
The facility failed to follow Registered Dietitian recommendations and notify the physician regarding a resident who experienced significant weight loss. The resident, who had diagnoses including essential hypertension, morbid obesity, and type 2 diabetes, was on a carbohydrate-controlled diet and had a documented 7% weight loss in 30 days. Despite multiple Interdisciplinary Team (IDT) Nutrition At Risk (NAR) notes recommending discontinuation of the carbohydrate control portion of the diet to improve intake, there was no documentation that the physician was notified of the significant weight loss or that the diet was changed as recommended. The resident's weight continued to decline over several months, and the care plan and orders were not updated to reflect the recommendations. Interviews with staff revealed that the Director of Nursing (DON) was unaware of the IDT NAR notes in the electronic medical record and relied solely on emailed reports from the Registered Dietitian, which did not include this resident. The DON acknowledged that physician notification should have occurred and that the NAR program was ineffective if recommendations were not communicated. The facility's policy required physician notification for significant changes in weight or nutritional status, but this was not documented in the resident's clinical record.
Failure to Follow Feeding Tube Placement and Infection Control Protocols
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper procedures during feeding tube site care for a resident with a history of hemiplegia, dysphagia, and malnutrition. The resident, who had severe cognitive impairment and required assistance with all activities of daily living, had orders for checking tube placement prior to medication administration, flushing the tube with water every shift, and maintaining the site with a split drain sponge and antibiotic ointment. During an observed care episode, the LPN performed hand hygiene and donned PPE before entering the room, but placed care supplies on an unprotected chair instead of a clean barrier. The nurse did not check the feeding tube placement before flushing it, as required by facility policy and physician orders. Additionally, after removing the old dressing, the nurse failed to perform hand hygiene or change gloves before handling supplies, touching the resident's drawer, and applying ointments to the feeding tube site, resulting in multiple breaches of infection control protocol. Interviews with the LPN and the DON confirmed that the nurse did not follow required procedures for verifying tube placement and maintaining hand hygiene and glove changes after contact with potentially contaminated surfaces. Facility policies specified the need for clean technique, use of barriers, and hand hygiene at specific steps, all of which were not followed during the observed care, placing the resident at risk for infection.
Failure to Follow Physician Orders for Oxygen Therapy and Humidification
Penalty
Summary
Facility staff failed to follow physician orders regarding oxygen therapy for a resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, and dependence on supplemental oxygen. The resident was observed multiple times with oxygen administered at five liters per minute via nasal cannula, despite a physician order specifying four liters per minute. The resident was cognitively intact and dependent on staff for most activities of daily living, and there was no evidence that she or her family adjusted the oxygen flow rate. Additionally, the humidity bottle attached to the oxygen concentrator was repeatedly found empty and not changed as required by physician order and facility policy, which called for weekly changes and as-needed replacement every shift. Nursing documentation indicated that the resident experienced a drop in oxygen saturation to 87 percent, prompting an increase in oxygen flow to five liters per minute and administration of an inhaler. However, there was no documentation that the physician was notified of this change in respiratory status or the adjustment in oxygen flow rate, as required by both physician order and facility policy. Staff interviews confirmed that the oxygen flow rate and humidification were not maintained per orders, and the physician was not notified of the changes. The facility's policy required oxygen to be administered according to physician orders and for staff to notify the physician of any changes in the resident's condition or oxygen administration.
Failure to Provide Individualized Dementia Interventions and Update Care Plans
Penalty
Summary
The facility failed to provide individualized interventions for dementia care to reduce or eliminate the need for psychoactive medications for a resident diagnosed with dementia and other mental health conditions. The resident had multiple diagnoses, including dementia with agitation, diabetes mellitus, insomnia, major depressive disorder, generalized anxiety disorder, and delusional disorder. The resident was prescribed several psychoactive medications, including antipsychotics, antidepressants, and anti-anxiety medications. Despite the use of these medications, the resident continued to display behavioral symptoms such as aggression, resistance to care, and agitation. Over a five-month period, documentation showed that the majority of the resident's behavioral events were successfully managed with non-chemical interventions, such as redirection, snacks, changing caregivers, and removing the resident from overstimulating environments. However, the care plans for the resident were not updated to reflect these effective non-pharmacological approaches, nor were resolved behavioral issues identified as such. The care plans also lacked new or personalized interventions, and there was no assessment of possible triggers for the resident's behaviors. Many care plan problems had not been updated for extended periods, and no new approaches were added despite changes in the resident's behavior and the effectiveness of non-chemical interventions. Interviews with staff confirmed that the resident responded well to individualized, non-pharmacological interventions, such as conversation, snacks, movies, and switching caregivers. Staff also noted that the resident did not experience hallucinations or delusions during the assessment period, and that most behaviors were typical of dementia. Despite this, the facility continued to justify the ongoing use of psychoactive medications without updating the care plan to reflect the resident's current needs and effective interventions. The facility's policy required person-centered, individualized care, but this was not consistently implemented for the resident in question.
Failure to Complete Shift-to-Shift Narcotic Reconciliation for Multiple Medication Carts
Penalty
Summary
The facility failed to ensure that shift-to-shift narcotic reconciliation was consistently completed for five out of six medication carts reviewed. During medication storage observations and record reviews, surveyors identified multiple instances across several units where the Controlled Drugs-Count Record lacked required signatures for shift-to-shift reconciliation of controlled substances. These omissions were noted on various dates and shifts, including day, evening, and night shifts, spanning several months and affecting the C Unit 1 and 2 hall carts, Advanced Acute Care Unit (AACU) cart, and both the short and long hall carts in the Acute Care Unit (ACU). Interviews with nursing staff and the Director of Nursing (DON) confirmed that the facility's expectation and policy require two licensed nurses to complete and sign the narcotic count at the start of each shift and during the exchange of keys. This process is intended to verify the accuracy of the controlled substance inventory and prevent drug diversion. However, the review of the Controlled Drugs-Count Records revealed numerous dates where this process was not documented as completed, indicating a failure to follow established procedures. The facility's policy, provided by the DON, outlines the requirement for clear, legible documentation of all controlled substances and mandates that two licensed nurses account for all controlled substances and access keys at the end of each shift. Despite this policy, the observed and documented lapses in shift-to-shift reconciliation demonstrate noncompliance with both facility policy and regulatory requirements for controlled substance accountability.
Failure to Label and Discard Insulin per Policy and Manufacturer Guidelines
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and timely disposal of insulin medications on one of three medication carts reviewed. During an inspection of the ACU Medcart with an LPN, several insulin products were found to be either undated, unlabeled, or not discarded after expiration. Specifically, a Lantus vial for a resident was opened and dated, but not discarded after the 28-day expiration period. Additionally, a Humalog vial and a Dulaglutide pen-injector for two other residents were found opened but undated, and an Insulin NPH pen-injector was opened and unlabeled. The LPN confirmed that insulin should be labeled with the date opened and discarded after 30 days, and that these items did not meet those requirements. Manufacturer recommendations for both Lantus and Humalog indicate that opened vials should be stored at room temperature or refrigerated for up to 28 days. The facility's own policy requires insulin pens to be clearly labeled with specific information, including the date dispensed and expiration date, and mandates disposal after 28 days or per manufacturer guidelines. The observed deficiencies were in direct violation of both manufacturer instructions and facility policy, as insulin products were not properly labeled or discarded in a timely manner.
Failure to Re-Offer and Educate on Pneumococcal Vaccination per CDC Guidance
Penalty
Summary
The facility failed to offer and educate a resident regarding Pneumococcal vaccines in accordance with CDC guidance. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, and was dependent on supplemental oxygen, had previously received a Pneumovax 23 vaccine prior to admission. Upon admission, the resident was cognitively intact and received education about the vaccine, subsequently declining it. However, the clinical record did not show that the vaccine was offered again after the initial refusal, despite CDC recommendations for re-offering at appropriate intervals. Interviews with the Infection Preventionist and the DON confirmed that residents who refused the Pneumococcal vaccine on admission were not re-offered the vaccine when they became eligible for subsequent doses. The facility's policy stated that immunizations would follow current CDC guidance and be offered as per federal, state, and local requirements, but the practice did not align with this policy, resulting in a failure to ensure ongoing vaccine offerings and education for the resident.
Failure to Re-offer COVID-19 Vaccine and Provide Ongoing Education
Penalty
Summary
The facility failed to provide ongoing education and offer COVID-19 vaccination to a resident in accordance with CDC guidance. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, and was dependent on supplemental oxygen, was cognitively intact at the time of assessment. Upon admission, the resident declined the COVID-19 vaccine after receiving education, with documentation indicating that the resident could change their mind and receive the vaccine at a later time with updated education. However, the clinical record did not show any further offerings of the COVID-19 vaccine to the resident after the initial declination in 2023. Interviews with the Infection Preventionist and the DON confirmed that residents who refused the vaccine on admission were not subsequently re-offered the vaccine when eligible for additional doses, contrary to CDC guidance and the facility's own immunization policy.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for medication administration for a resident with a history of heart failure, hypertension, constipation, dementia, and schizoaffective disorder. The resident was prescribed metoprolol succinate extended release to be administered in the evening, with instructions to hold the medication if the systolic blood pressure (SBP) was below 100 or the heart rate (HR) was less than 60 beats per minute (BPM). On one occasion, the resident's SBP was 110 and HR was 62 BPM, yet the medication was held without documentation of the reason. Additionally, the resident was prescribed hydralazine hydrochloride with instructions to hold the medication if the SBP was below 110 or HR was below 60 BPM. Despite these parameters, the medication was administered on multiple occasions when the SBP was below the threshold, and there was no documentation indicating the medication was held. The Director of Nursing (DON) confirmed that medications should be administered or held according to physician orders and within the prescribed parameters. The facility's policy on medication administration requires obtaining and recording vital signs and holding medications if vital signs fall outside the physician's prescribed parameters. The deficiency was identified during a review of the resident's closed clinical record and was related to complaints IN00451394 and IN00451774.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist to oversee the infection prevention and control program, as required. During the survey, it was found that the facility did not have a certified Infection Preventionist for two of the five days of the survey and had not had one since February 5, 2024. The Administrator initially indicated that RN 12 was the Infection Preventionist, but it was later revealed that the Assistant Director of Nursing (ADON) had been acting in that role since January 2024 without the necessary certification until July 10, 2024. Further interviews revealed that RN 13, who was certified, had not been actively involved in the infection control program since February 5, 2024, despite being expected to train and consult for the program. The facility's policy required the Infection Preventionist to have completed specialized training, which the ADON only completed during the survey. This lack of a qualified Infection Preventionist had the potential to affect all 98 residents in the facility.
Infection Control Deficiencies in Isolation and Precautions
Penalty
Summary
The facility failed to implement and utilize proper infection prevention and control practices for three residents, leading to deficiencies in contact isolation, enhanced barrier precautions (EBP), and diagnostic testing. Resident B was observed with both an EBP sign and a contact isolation sign on their door, yet an LPN entered the room without wearing a gown, despite the requirement for gown and gloves for all interactions. Resident B had a diagnosis of MRSA and was on antibiotic treatment, necessitating strict adherence to contact isolation protocols. Similarly, Resident C was in an EBP room, and an LPN was observed handling the resident's urinary drainage bag without wearing a gown, contrary to the physician's order for gown and gloves during all interactions. Resident C had diagnoses that included obstructive and reflux uropathy and required enhanced precautions due to the presence of an indwelling catheter and bowel incontinence. Resident 99, who was experiencing loose stools potentially due to antibiotic use, was not placed in contact isolation while awaiting C. diff test results. The clinical record lacked documentation of the stool specimen collection, and the resident was not restricted to her room, increasing the risk of infection spread. The facility's failure to collect the specimen and notify the physician of the oversight, along with the lack of appropriate isolation measures, highlighted significant lapses in infection control practices.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program as per its policy, which had the potential to affect all 98 residents. A review of the Infection Control Surveillance Binder for May and June 2024 revealed deficiencies in documentation and monitoring. In June, the binder noted 19 infections with 19 residents receiving antibiotics, but lacked details such as resident names, infection types, and criteria for treatment. Similarly, in May, the binder recorded 18 infections with 18 residents receiving antibiotics, but the documentation was incomplete, missing information on symptoms, infection types, and whether the criteria for antibiotic treatment were met. The Assistant Director of Nursing (ADON), who served as the facility's infection preventionist, admitted during an interview that she did not complete or review the necessary forms herself. She relied on unit managers to fill out the Revised McGeer Criteria for Infection Surveillance Checklist forms when an infection was suspected, but she did not receive any forms in June and did not follow up with the unit managers. Her role was limited to generating the monthly report, and she did not confirm the appropriateness of antibiotic usage. The facility's policy on the Antibiotic Stewardship Program outlined responsibilities for tracking antibiotic use and monitoring adherence to evidence-based criteria, which were not fulfilled.
Inconsistent Urinary Drainage Device Management
Penalty
Summary
The facility failed to provide consistent interventions for maintaining urinary drainage devices for two residents, identified as Residents B and C. Resident B, who had a urostomy due to obstructive uropathy and other medical conditions, was found to have his urinary drainage bag not emptied regularly, leading to it being excessively full on multiple occasions. Observations revealed that the bag was not emptied until it was completely full, with volumes reaching up to 3050 milliliters. Staff interviews confirmed that the aides were responsible for emptying the bags every shift, but this was not consistently done, as evidenced by the resident's reports and the observations made by the surveyors. Resident C, who had a suprapubic urinary catheter, also experienced similar issues with his urinary drainage bag not being emptied regularly. During an observation, it was noted that the bag had leaked onto the floor, and the resident reported that the staff allowed the bag to become very full before emptying it. The resident's clinical records indicated a lack of monitoring of the catheter output on several occasions, and the resident expressed concerns about the night shift not emptying the bag as required. The facility's policy on catheter care required that drainage bags be emptied when half-full or every 3 to 6 hours, but this was not adhered to in the cases of Residents B and C. Interviews with the Director of Nursing and other staff confirmed that the urinary drainage bags should have been emptied every shift and that any issues with leaking should be reported immediately. The failure to follow these protocols resulted in the deficiencies observed during the survey.
Failure to Complete Timely Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days of a determined status change for two residents. Resident 18, diagnosed with Chronic Obstructive Pulmonary Disorder (COPD), morbid obesity, and dependent on supplemental oxygen, was admitted to hospice services as per a physician's order. However, the facility did not complete a Significant Change MDS assessment following this change, instead conducting an annual MDS assessment, which was not appropriate for the status change. The MDS Coordinator, who started her position in April 2024, acknowledged the oversight and indicated that the Resident Assessment Instrument (RAI) manual was used for guidance. Similarly, Resident 203, with diagnoses including Alzheimer's Disease, protein-calorie malnutrition, and diastolic heart failure, was admitted to hospice services. The clinical record lacked a Significant Change assessment for this new hospice service. The MDS Coordinator confirmed that a Significant Change assessment was necessary following the new hospice order. Although an appropriate assessment was completed when the resident was removed from a previous hospice provider, the subsequent status change was not properly assessed. The RAI manual specifies that a Significant Change in Status Assessment must be completed within 14 days of a hospice election, which was not adhered to in these cases.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of Quarterly Minimum Data Set (MDS) assessments for a resident, as required every three months. Resident 65, who has diagnoses including heart failure, paranoid schizophrenia, bipolar disorder, and anxiety disorder, had two instances of late MDS assessments. The first assessment, with an Assessment Reference Date (ARD) of 12/13/23, was completed 15 days late on 1/11/24. The second assessment, with an ARD of 9/12/23, was completed one day late on 9/27/23. During an interview, the MDS Coordinator, who started her role in April 2024, acknowledged the late completion of these assessments. The current Resident Assessment Instrument (RAI) manual specifies that the Quarterly MDS completion date must be no later than 14 days after the ARD.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure the timely submission of Minimum Data Set (MDS) assessments for a resident reviewed for assessment submission. The resident, who had diagnoses including heart failure, paranoid schizophrenia, bipolar disorder, and anxiety disorder, had a Quarterly MDS assessment with an Assessment Reference Date (ARD) of May 6, 2024, which was completed on May 13, 2024. Although the assessment was completed on time, the record lacked a transmission date. During an interview, the MDS Coordinator indicated she was unaware that this assessment had not been transmitted and suggested it might be an error in the program, as the document was marked as not required for transmission. She planned to consult with her consultant for further direction. According to the current RAI manual, the Quarterly MDS submission date must be no later than the completion date plus 14 calendar days.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to monitor the fluid intake of a resident with end-stage renal disease (ESRD) who was on a fluid restriction. The resident, who also had heart failure and was dependent on renal dialysis, had a physician's order for a 1500 ml fluid restriction, with specific allocations for dietary and nursing. Despite this, observations revealed multiple Styrofoam cups and soda cans at the resident's bedside, indicating a lack of adherence to the fluid restriction. The care plans in place highlighted the need for fluid restriction and monitoring, yet the electronic medical record lacked documentation of fluid intake amounts. Interviews with staff, including an LPN and the Director of Nursing (DON), revealed a lack of awareness and monitoring of the resident's fluid intake. The facility's policy on fluid restriction, which required recording fluid intake in accordance with physician orders, was not followed. The bedside report and point of care charting also failed to indicate the resident's fluid restriction, contributing to the deficiency in care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 407 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Muncie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Pointe Health And Rehab | 0.3 mi | ★★★★★ | 4 | 0 |
| Morrison Woods Health Campus | 0.9 mi | ★★★★★ | 0 | 0 |
| Westminster Village Muncie Inc | 1.4 mi | ★★★★★ | 10 | 0 |
| Woodlands The | 1.6 mi | ★★★★★ | 0 | 0 |
| Waters Edge Village | 2.3 mi | ★★★★★ | 5 | 0 |
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