Inspection Reports for Brickyard Healthcare – Elkhart Care Center
1001 W HIVELY AVE, IN, 46517
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 24, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a pattern of deficiencies primarily involving care planning, medication management, food safety, emergency preparedness, and life safety code compliance. Notable issues included a substantiated failure to timely report an abuse allegation in January 2025, food temperature problems in October 2024, and multiple care and safety deficiencies in mid-2024 and early 2023, including a resident death linked to improper diet supervision. Most complaint investigations were unsubstantiated except for a few substantiated cases with cited deficiencies, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows some improvement in recent months with no deficiencies found in the latest investigations.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
321% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 129
Capacity: 129
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00457200 and IN00458089.
Complaint Details
Investigation of complaints IN00457200 and IN00458089 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00457200 and IN00458089 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 129
Total Capacity: 129
Medicare Census: 5
Medicaid Census: 92
Other Payor Census: 32
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00451700.
Complaint Details
Complaint investigation IN00451700 was reviewed and found to be in compliance.
Findings
Brickyard Healthcare - Elkhart Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 1
Date: Jan 22, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451700 regarding allegations of abuse at the facility.
Complaint Details
Complaint IN00451700 was substantiated with federal/state deficiencies cited related to the allegations of abuse involving Resident B. The allegation was reported late by Employee 6, who failed to immediately notify the Administrator as required.
Findings
The facility failed to implement their policy related to reporting an allegation of abuse for 1 of 3 residents reviewed (Resident B). The allegation involved an employee spraying a resident with room deodorizer and inappropriate conduct. The facility suspended the employee, reported the incident to the State Agency, and initiated an investigation. The Administrator acknowledged a failure in timely reporting by a staff member.
Deficiencies (1)
Failed to implement policy related to reporting an allegation of abuse for 1 of 3 residents reviewed (Resident B).
Report Facts
Census: 112
Total Capacity: 112
Medicare residents: 2
Medicaid residents: 84
Other residents: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Knisley | Executive Director | Signed report and involved in administrative response |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Date: Jan 21, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451446.
Complaint Details
Investigation of Complaint IN00451446 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00451446 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 112
Total Capacity: 112
Medicare Census: 2
Medicaid Census: 84
Other Payor Census: 26
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
This visit was for the investigation of Complaint IN00451054.
Complaint Details
Complaint IN00451054 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations of Complaint IN00451054 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census: 112
Total Capacity: 112
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 84
Census Payor Type - Other: 26
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Date: Jan 9, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449811.
Complaint Details
Complaint IN00449811 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 112
Total Capacity: 112
Medicare Census: 3
Medicaid Census: 87
Other Payor Census: 22
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00443191 completed on October 4, 2024.
Complaint Details
Complaint investigation IN00443191 was reviewed and found to be in compliance.
Findings
Brickyard Healthcare - Elkhart Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Inspection Report
Follow-Up
Census: 111
Capacity: 175
Deficiencies: 0
Date: Oct 15, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 08/27/24.
Findings
At this Emergency Preparedness PSR, the facility was found in compliance with Emergency Preparedness Requirements. At the Life Safety Code PSR, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid and Life Safety from Fire standards.
Report Facts
Certified beds: 175
Census: 111
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 1
Date: Oct 4, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00443784, IN00443631, IN00443636, IN00443671, and IN00443191) at Brickyard Healthcare - Elkhart Care Center.
Complaint Details
Complaint IN00443191 was substantiated with Federal/State deficiencies cited at F804 related to food temperature issues. Other complaints (IN00443784, IN00443631, IN00443636, IN00443671) had no deficiencies related to allegations.
Findings
The facility was found deficient related to Complaint IN00443191 for failing to ensure food was served at palatable temperatures in the main kitchen, potentially affecting 110 of 120 residents. Other complaints had no deficiencies cited.
Deficiencies (1)
Failed to ensure food was served at palatable temperatures in 1 of 1 kitchens observed (Main Kitchen), with hot foods on the steam table below required temperatures and food served cold on trays.
Report Facts
Residents potentially affected: 110
Census: 120
Total capacity: 120
Food temperatures observed: 105
Food temperatures observed: 123
Food temperatures observed: 118
Food temperatures observed: 128
Food temperatures observed: 123
Food temperatures observed: 141
Food temperatures observed: 140
Food temperatures observed: 80
Food temperatures observed: 85
Food temperatures observed: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook 1 | Observed and confirmed food temperatures during meal service; indicated hot food temps should be held at or above 140 F on steam table | |
| Dietary Manager | Indicated hot foods were to be temperature checked at the steam table and educated food service staff on proper food temperature policies | |
| Administrator | Indicated hot foods should be served at appropriate temperatures and not below | |
| Director of Nursing | Provided current facility policy on maintaining sanitary tray line and food temperature monitoring | |
| Dietary Director | Responsible for educating staff, monitoring food temperatures, and presenting audit summaries to Quality Assurance committee |
Inspection Report
Life Safety
Census: 112
Capacity: 175
Deficiencies: 7
Date: Aug 27, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively, covering the period 08/26/24 to 08/27/24.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including deficiencies in emergency communication plans, egress door accessibility and signage, sprinkler system installation and maintenance, fire department connection visibility, smoking regulations, and staff training on oxygen transfilling procedures.
Deficiencies (7)
Failed to ensure the emergency preparedness communication plan includes primary and alternate means for communication with facility staff and emergency management agencies.
Failed to ensure means of egress through one exit were readily accessible; exit gate was magnetically locked without posted code.
Failed to ensure one door was properly marked with 'NO EXIT' signage to prevent confusion.
Failed to maintain sprinkler escutcheon covering annular space around sprinkler head in front lobby.
Failed to ensure fire department connection was visible and accessible; obscured by landscaping with no directional signage.
Failed to provide a documented smoking policy or regulations as required by Life Safety Code.
Failed to ensure staff were properly trained on oxygen transfilling procedures.
Report Facts
Certified beds: 175
Census: 112
Number of exits affected: 1
Number of residents affected by egress door deficiency: 45
Number of residents affected by exit signage deficiency: 24
Number of smoke compartments: 8
Number of cigarette butts observed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Knisley | Executive Director | Interviewed regarding emergency preparedness communication plan and oxygen safety training. |
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness communication, egress doors, sprinkler system, fire department connection visibility, smoking regulations, and oxygen safety training. | |
| Maintenance Assistant | Interviewed and involved in findings related to emergency preparedness communication, egress doors, sprinkler system, fire department connection visibility, and smoking regulations. |
Inspection Report
Annual Inspection
Census: 111
Capacity: 111
Deficiencies: 14
Date: Aug 5, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00438189 and IN00435892.
Complaint Details
Complaint IN00438189 and IN00435892 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including management of resident funds, baseline and comprehensive care plans, activities, quality of care related to edema and antibiotic administration, infection control, medication management, and food handling. No deficiencies were cited related to the complaints investigated.
Deficiencies (14)
Failed to ensure resident funds were available on the same day of the request and for the desired amount for 4 residents.
Failed to ensure a surety bond sufficiently covered the total monies in the Resident Fund account affecting 56 residents.
Failed to provide accurate orders for resuscitative wishes for 2 residents.
Failed to ensure baseline care plans were initiated or completed timely for 4 residents.
Failed to ensure comprehensive person-centered care plans were created related to behaviors, urinary tract infection, constipation, impaired vision, and edema for 5 residents.
Failed to provide resident-centered activities for 1 resident.
Failed to ensure edema was monitored for 1 resident and antibiotic medication was administered timely for 1 resident.
Failed to provide a range of motion program to prevent further contractures for 1 resident.
Failed to provide peripherally inserted central catheter care for 1 resident; PICC line dressing was folded exposing insertion site.
Failed to provide adequate tracheostomy care and proper positioning of tracheostomy collar for 1 resident.
Failed to verify controlled substance counts for 1 medication cart; missing signatures on narcotic count sheets.
Failed to ensure appropriate diagnosis for a resident receiving antipsychotic medication.
Failed to ensure food was handled appropriately, foods were sealed and dated properly, and staff did not contaminate food while serving.
Failed to ensure staff changed gloves and performed hand hygiene when providing perineal care for 1 resident.
Report Facts
Residents with facility-managed personal funds: 4
Residents with resident fund accounts: 56
Residents reviewed for baseline care plans: 27
Residents reviewed for comprehensive care plans: 23
Residents reviewed for activities: 3
Residents reviewed for edema: 1
Residents reviewed for antibiotic use: 2
Residents reviewed for range of motion: 2
Residents reviewed for PICC line care: 5
Residents reviewed for tracheostomy care: 1
Medication cart narcotic count sheets missing signatures: 9
Residents reviewed for unnecessary antipsychotic medications: 5
Residents receiving meals: 115
Residents reviewed for personal care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Oliver | VP Regulatory Compliance | Signed the report. |
| LPN 2 | Provided information on passive range of motion and tracheostomy care. | |
| CNA 16 | Observed providing perineal care without changing gloves or hand hygiene. | |
| CNA 17 | Observed placing thumb on food surface while serving. | |
| CNA 18 | Observed holding meal tray on shoulder with hair touching tray. | |
| Director of Nursing | Provided multiple interviews and policies, involved in corrective actions. | |
| Activity Director | Provided observations and education on activity care plans. | |
| Business Office Manager | Provided information on resident funds and surety bond. | |
| LPN 13 | Interviewed regarding resident fund withdrawal limits. | |
| QMA 19 | Observed oxygen saturation and care for Resident 93. |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 5, 2024
Visit Reason
The inspection was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
Brickyard Healthcare Elkhart Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the Paper Compliance Review.
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426073.
Complaint Details
Complaint IN00426073 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00426073 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 3
Medicaid census: 58
Other payor census: 26
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
This visit was conducted to investigate complaints IN00420522, IN00421933, IN00422139, and IN00422222 at Brickyard Healthcare - Elkhart Care Center.
Complaint Details
Complaints IN00420522, IN00421933, IN00422139, and IN00422222 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of the complaints.
Report Facts
Census SNF/NF: 93
Total Capacity: 93
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 19
Inspection Report
Follow-Up
Census: 93
Capacity: 175
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey to verify compliance following prior surveys conducted on 08/10/23.
Findings
At this Post Survey Revisit, Brickyard Healthcare - Elkhart Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for the electrical room in the maintenance shop.
Report Facts
Certified beds: 175
Census: 93
Generator capacity: 500
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418041 and IN00415713.
Complaint Details
Complaint IN00418041 and Complaint IN00415713 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00418041 and IN00415713 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF: 93
Total Capacity: 93
Census Payor Type Medicare: 1
Census Payor Type Medicaid: 74
Census Payor Type Other: 18
Inspection Report
Life Safety
Census: 95
Capacity: 175
Deficiencies: 11
Date: Aug 10, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements related to generator testing and inspections, life safety code requirements including sprinkler coverage, exit door locking and signage, fire alarm system maintenance, corridor door latching, fire drills, generator maintenance and testing, power strip usage, and oxygen transfilling procedures.
Deficiencies (11)
Generator lacked monthly load testing and weekly visual inspections as required by Life Safety Code and NFPA 110.
Electrical room in maintenance shop was not sprinklered.
Exit doors #5, #7, and #8 in 200-wing were magnetically locked with incorrect posted codes, impeding egress.
One exit sign in North Wing was not illuminated.
Hardwired heat detector in kitchen was dangling and not properly mounted.
Four resident room corridor doors failed to latch properly.
Missing documentation for monthly generator load testing for 2 months and weekly inspections for 11 weeks; incomplete load bank test documentation.
Generator automatic transfer switch will not transfer building load automatically; repairs pending.
Two power strips were used to supply refrigerators, which is not permitted for high current draw equipment.
Oxygen transfilling room door was held open during transfilling and lighting was not functioning properly.
Fire drills were not conducted on each shift for 2 of 4 quarters in 2023.
Report Facts
Certified beds: 175
Census: 95
Deficiencies cited: 11
Fire drills missing: 4
Generator load testing missing months: 2
Weekly generator inspections missing weeks: 11
Generator exercise duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Knisley | Executive Director | Signed report |
| Maintenance Director | Interviewed and involved in findings related to generator testing, fire drills, door locking, oxygen transfilling, and other deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
Paper Compliance Review to the Recertification and State Licensure Survey and Investigation of Complaint IN00412325.
Complaint Details
Investigation of Complaint IN00412325 completed on July 27, 2023; found to be in compliance.
Findings
Brickyard Healthcare Elkhart Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey and Complaint Investigation.
Inspection Report
Annual Inspection
Census: 95
Capacity: 95
Deficiencies: 12
Date: Jul 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00412325 and IN00413904.
Complaint Details
Complaint IN00412325 - Federal/state deficiencies related to the allegations are cited at F755. Complaint IN00413904 - No deficiencies related to the allegations are cited.
Findings
The facility was found deficient in multiple areas including medication administration, advance directive documentation, notification of medication availability issues, transfer documentation, care planning for CPAP use, timely shower provision, sanitation of CPAP equipment, medication availability, medication storage and labeling, food safety and sanitation, and environmental safety and maintenance.
Deficiencies (12)
Failed to ensure standards of care of visually observing a resident take their medications.
Failed to ensure Physician Orders for Scope of Treatment (POST) forms were accurately completed.
Failed to notify physician timely of missed doses of unavailable medication.
Failed to ensure pertinent transfer and resident clinical information was completed for transfers.
Failed to provide transfer form information at time of hospitalization.
Failed to provide a care plan for the use of a continuous positive airway pressure (C-Pap) device.
Failed to ensure showers were provided timely for a resident.
Failed to provide sanitation of the continuous positive airway pressure (C-Pap) equipment.
Failed to ensure medications were available from the pharmacy for residents.
Failed to ensure medications were kept in locked carts when unattended, medication storage areas free from loose medications, and medications dated when opened.
Failed to ensure food safety and sanitation in kitchen and pantries including clean environment, proper food storage temperatures, disposal of expired foods, and labeling and dating of foods brought in by residents.
Failed to ensure a safe, clean, and comfortable environment related to broken towel rack, plastic wrapped power strip cord, stained ceiling tiles, broken heater, dead bugs in light covers, and black mold on vents.
Report Facts
Survey dates: 6
Census Bed Type: 95
Census Payor Type: 95
Medication administration observations: 3
Physician Orders for Scope of Treatment (POST) audits: 5
Medication availability audits: 5
Transfer and discharge audits: 5
Care plan audits for CPAP: 5
CPAP cleaning order audits: 5
Shower audits: 5
Medication storage audits: 5
Food safety audits: 7
Environmental safety audits: 7
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 1
Date: Apr 27, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404852, IN00405551, and IN00407017. Deficiencies related to complaint IN00407017 were cited.
Complaint Details
Complaint IN00407017 was substantiated with deficiencies cited related to the allegations. Complaints IN00404852 and IN00405551 had no deficiencies related to the allegations.
Findings
The facility failed to provide appropriate supervision and the correct textured diet for one resident on a mechanically altered diet, which resulted in the resident's death due to choking. The investigation revealed that the resident was served inappropriate food items such as potato chips and cheese puffs, which were not suitable for the prescribed mechanical soft diet.
Deficiencies (1)
Failure to provide appropriate supervision and the appropriate textured diet for 1 of 3 residents reviewed for mechanically altered diets that resulted in death.
Report Facts
Census: 90
Total Capacity: 90
Medicare Census: 4
Medicaid Census: 76
Other Payor Census: 10
Inspection Report
Follow-Up
Census: 90
Capacity: 90
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00383543, IN00400925, and IN00401849 completed on March 2, 2023.
Complaint Details
This was a follow-up visit related to three complaints (IN00383543, IN00400925, IN00401849). All complaints were corrected.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaints. All three complaints were corrected.
Report Facts
Census: 90
Total Capacity: 90
Medicare Census: 4
Medicaid Census: 71
Other Payor Census: 15
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 6
Date: Mar 2, 2023
Visit Reason
Investigation of multiple complaints alleging various deficiencies at Brickyard Healthcare - Elkhart Care Center, including quality of care and regulatory compliance issues.
Complaint Details
The investigation was triggered by multiple complaints (IN00383064, IN00383207, IN00383543, IN00386854, IN00391650, IN00393676, IN399522, IN00400925, IN00401849, IN00401943). Several complaints resulted in cited deficiencies related to quality of care, wound care, catheter care, and other regulatory issues.
Findings
The facility was found to have multiple deficiencies including failure to provide written notice of roommate changes, inadequate monitoring and treatment of wound VAC therapy, failure to prevent pressure ulcer deterioration, inadequate catheter care leading to infection and sepsis, failure to monitor diuretic therapy, and lack of quarterly QAPI meetings.
Deficiencies (6)
Failure to ensure 2 of 3 residents received written notice of roommate change when a second resident was assigned to a room certified for one resident.
Failure to monitor and follow physician orders regarding wound VAC therapy for 1 of 1 residents.
Failure to provide appropriate treatment and services to prevent deterioration and infection of pressure ulcers for 1 of 1 residents.
Failure to ensure thorough assessments and care for Foley catheter use resulting in sepsis and death for 1 of 3 residents.
Failure to monitor a resident receiving diuretic therapy for electrolyte imbalances and adverse effects.
Failure to conduct quarterly Quality Assurance and Performance Improvement (QAPI) meetings with required interdisciplinary participation.
Report Facts
Census: 90
Total Capacity: 90
Deficiencies cited: 6
Dates of survey: 2023-02-21 to 2023-03-02
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Kennedy | Executive Director | Signed report and plan of correction |
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Nov 28, 2023
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Jul 27, 2023
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