Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 - Elkhart Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment sustained burns after spilling coffee in her lap during meal service. The coffee temperature logs showed 195 F readings, while the facility’s log form called for 150 F to 160 F, and the DON stated the aide recorded the coffee maker’s LCD display instead of checking the coffee with a probe. The resident was sent to the ER and later found to have full-thickness burns to both inner thighs.
Failure to report a resident burn to the State Agency. A resident with severe cognitive impairment spilled hot coffee in her lap and sustained burns to the groin and bilateral thighs, with nursing notes, ER records, and wound assessments documenting blistering and full-thickness burns. Dietary records showed coffee temperatures were documented at 195 F even though the log required 150 F to 160 F, and the Dietary Manager stated the coffee had not been manually checked with a probe. The Administrator stated the burn was not reported because he believed only basic first aid had been needed and acknowledged the facility did not fully investigate the root cause.
A resident with CHF, CKD, DM2, COPD, and acute metabolic acidosis, who had identified it as very important to have family involved in care and had designated a granddaughter as emergency contact, experienced multiple new treatments and changes in condition without notification of the chosen representative. Nursing and physician documentation showed repeated new orders for labs, analgesics, hypoglycemics, insulin adjustments, antibiotics for UTI and cellulitis, IV and hypodermoclysis fluids for elevated BUN, diuretics for lower extremity fluid seepage, nitroglycerin for chest pain, and a chest X-ray, with no evidence that the representative was informed. Progress notes also described chronic confusion in the resident, while the facility’s own Notification of Change policy required notifying the resident’s representative of new treatments and significant health status changes, which did not occur, and the emergency contact confirmed she had not been updated on these changes.
A resident with CHF, CKD stage 3, DM2, and acute metabolic acidosis had a physician order for metoprolol 25 mg BID with instructions to hold the dose if SBP was below a specified threshold or if pulse was below 60 bpm. Review of the MAR showed that nursing staff administered metoprolol on several occasions despite SBP readings below the ordered hold parameter. During interview, the ADON stated that nursing staff should have followed the physician’s orders, and facility policy required provision of physician-ordered services according to professional standards of quality.
A resident with cognitive and physical impairments was involved in a verbal altercation with a CNA after the resident ran over the CNA's foot with a motorized wheelchair. The CNA raised her voice at the resident, and the resident alleged physical contact. Staff intervened to de-escalate the situation, and the incident was documented and reported. The facility failed to ensure the resident was free from verbal abuse as required by policy.
Expired food was found in the kitchen walk-in cooler, including corn, chicken, yogurt, and lime juice past their use-by dates. The Regional Certified Dietary Manager stated the items should have been discarded by the expiration dates, and the report noted the issue had the potential to affect 112 of 114 residents who ate food from the kitchen.
Unclean and Infested Resident Areas: The facility failed to maintain a clean, sanitary, and comfortable environment on the 400 and 500 halls. Residents reported gnats and flies in rooms, and surveyors observed live flies, fruit flies throughout the memory care unit, stained walls and curtains, gouged and scuffed walls, a broken window blind, cracked trim, a sticky urine-smelling floor, dead bugs and gnats in a shower room sink, dried brown residue in the tub and on a bedside commode bucket, and crumbs, cobwebs, and debris in a lounge area.
Unnecessary psychotropic medication use was identified for two residents. One resident received olanzapine for depression even though the DON stated depression was not an appropriate diagnosis and there was no other documented symptom or diagnosis to support its use. Another resident had a PRN lorazepam order for anxiety and agitation, but the EMR lacked physician documentation supporting use beyond 14 days, and the DON stated the medication should not have continued that long.
A resident with multiple serious diagnoses developed a new unstageable deep tissue injury to the right lateral forefoot, but the wound care plan was not initiated until weeks later. Another resident with PTSD, behavioral disturbance, and a history of abuse had a care plan that lacked individualized, person-centered interventions despite staff identifying triggers such as loud noises and overstimulation and noting strategies that helped the resident.
The facility failed to follow ordered parameters for BP meds and insulin management for several residents. A resident with multiple cardiac and renal conditions received Midodrine when SBP was above the hold limits, another resident’s Midodrine order used an incorrect symbol that led to administration despite low BP readings, and a resident with diabetes had a severe blood glucose elevation without documentation of the ordered Lispro dose or repeat BG check. Two additional residents also received Propranolol or Midodrine despite BP or HR readings outside ordered parameters.
A resident with hemiplegia, impaired ROM, and dependence for bed mobility and transfers had a physician order for a hand orthosis to be worn in the morning and removed at bedtime, but the orthosis was not in place during repeated observations and the resident’s left hand was found fisted while in bed. The resident said she had an orthosis but did not know where it was, staff reported it had not been worn recently or was used only when out of bed, there was no care plan for the hemiplegia or orthosis use, and the DON stated no policy for orthosis use or ROM was available.
The facility failed to ensure ordered meds were available and given for one resident with multiple chronic conditions, including diabetes, epilepsy, AFib, and depression; nursing notes showed Apixaban, Pantoprazole, Pregabalin, and Glipizide were unavailable at times and not administered, even though the DON said they should have been obtained from emergency drug stock. The facility also failed to ensure another resident receiving Seroquel/quetiapine for dementia-related behaviors had adequate monitoring for adverse effects, as only one AIMS assessment was found in the past 12 months and the DON confirmed there was no other documentation of such assessment.
A resident reported an alleged abuse incident involving an employee who inappropriately used a room deodorizer. The resident informed another employee, who failed to report the allegation immediately as required by the facility's policy. The Administrator was only informed days later, leading to a delay in addressing the situation.
The facility failed to serve food at palatable temperatures, affecting 110 residents. Observations showed hot foods on the steam table were below required temperatures, and meals transported on non-insulated carts further cooled down. Staff and residents confirmed the issue, with residents expressing dissatisfaction over cold meals. The facility's policy requires maintaining hot foods at or above 135°F.
The facility failed to ensure proper food handling and storage, affecting 114 residents. Observations revealed undated and improperly stored food items, and staff were seen mishandling meal trays, compromising food safety. The facility lacked a policy on meal tray delivery.
The facility failed to provide residents with timely access to their personal funds, restricting withdrawals to weekdays and imposing an unauthorized five-dollar limit. Staff were unaware of these restrictions, which contradicted facility policy.
The facility did not ensure that the surety bond for the Resident Fund account was sufficient to cover the total funds held, which amounted to $286,128.00. This amount was unusually high due to a closed account with funds from a home sale. The surety bond was only set at $250,000, contrary to the facility's policy requiring the bond to match or exceed the total resident funds. The Executive Director was unaware of the reason for the insufficient bond coverage.
The facility failed to timely initiate and complete baseline care plans for four residents with specific medical needs, including dialysis, tube feeding, falls, and pressure ulcers. The care plans lacked necessary goals and interventions and were not completed within the required 48-hour timeframe, as confirmed by the DON and Executive Director.
The facility failed to create comprehensive person-centered care plans for several residents, resulting in deficiencies in addressing their medical and psychosocial needs. A resident with dementia lacked individualized interventions for antipsychotic use, while another with Alzheimer's had unaddressed vision issues. Additional residents experienced inadequate care planning for conditions like edema, UTI, and constipation, as confirmed by the DON.
The facility failed to accurately document the resuscitative wishes of two residents. One resident had conflicting documentation between a DNR order and a full code status in their care plan and physician's order. Another resident lacked documentation of their code status preferences entirely. These discrepancies were confirmed by staff interviews and violated the facility's policy on communication of code status.
A resident with significant medical conditions and unresponsiveness was not provided with preferred activities such as music and television, despite documented preferences and a facility policy emphasizing resident-centered activities. The Activity Director noted the absence of a television and lack of one-on-one visits since the resident's return from hospitalization.
The facility failed to monitor edema for a resident with significant bilateral edema and did not timely administer antibiotics for another resident with an infected toe. The care plans lacked specific monitoring for edema, and assessments were inconsistent. Additionally, a delay in administering Doxycycline for cellulitis occurred due to mishandled medication orders, with no policy on timely antibiotic administration.
A resident with a history of cerebral infarction and in a persistent vegetative state did not receive a prescribed range of motion (ROM) program to prevent contractures. Observations showed the resident's hands in a fist-like position and knees bent, with a cushioned boot not in use. Despite physician's orders for ROM exercises and splints, there was no documentation of the program being implemented, and the splints were discontinued due to anxiety. An LPN confirmed the resident's tight hands and knees, indicating a lack of proper ROM care.
A resident with a PICC line for IV medications had a dressing that was improperly maintained, exposing the insertion site. Despite a physician's order for weekly and as-needed dressing changes, the dressing remained compromised for several days. The resident's medical conditions required strict infection control, but the facility's policy was not followed.
A resident with a tracheostomy was observed with a misaligned oxygen collar, leading to low oxygen saturation levels. The facility lacked comprehensive physician's orders for tracheostomy care, and the resident's care plan was not followed, as evidenced by missing entries in the treatment records. Staff interviews confirmed the absence of necessary orders for complete tracheostomy care.
The facility did not verify controlled substance counts for a medication cart in the SW Unit. Missing signatures were found on the controlled medication log book for several dates, indicating a failure to complete the required verification by the oncoming and offgoing nurse or QMA. The facility's policy mandates that two licensed nurses account for all controlled substances and access keys at the end of each shift, which was not followed.
A resident was prescribed Zyprexa for dementia with agitation without an appropriate diagnosis, as noted in a psychiatric note lacking an approved diagnosis. Despite the medication being clinically contraindicated, it was continued due to perceived benefits outweighing risks. The DON confirmed the absence of an appropriate diagnosis, contrary to the facility's policy requiring documentation of adequate indications for medication use.
A resident was found on wet bed linens and expressed dissatisfaction with their care. A CNA failed to follow proper hand hygiene and glove-changing protocols during perineal care, using the same gloves throughout the process and not washing hands, contrary to the facility's policy.
Hot coffee served at unsafe temperature
Penalty
Summary
The facility failed to ensure hot coffee was served at a safe temperature for a resident with severe cognitive impairment who required supervision for eating. Resident B was admitted with diagnoses including metabolic encephalopathy and vascular dementia, and the resident’s annual MDS indicated severe cognitive impairment. On 3/19/26, a CNA brought the resident back from the dining room after the resident spilled coffee in her lap, and the resident was noted to have redness with fluid-filled blisters to the groin and bilateral thigh areas with mild discomfort. The resident’s responsible party requested transfer to the ER for treatment and evaluation. The ER record documented that the resident presented after sustaining a burn when coffee was spilled onto her lap, with partial burns and blistering to the left thigh. A subsequent wound nurse skin check identified new full-thickness burns to the right and left inner thighs near the groin region, with measurements of 8.5 cm by 4 cm and 4 cm by 3.5 cm, respectively. A physician progress note later documented burns to both inner thighs and the need for ongoing skin surveillance to prevent secondary complications and delayed healing. The Dietary Manager provided monthly coffee and hot water temperature logs showing coffee temperatures recorded at 195 F for breakfast, lunch, and dinner from 1/1/26 through 4/29/26, while the facility log form indicated coffee should be maintained at 150 F to 160 F. During observation, the coffee maker displayed a ready-to-brew temperature of 195 F. The Dietary Manager stated Dietary Aide 3 was responsible for manually checking coffee temperature with a probe before service, but the aide had instead recorded the coffee maker’s LCD display temperature. The Dietary Manager also stated the documented temperatures were too hot and that there was no way to know the actual coffee temperature since 1/1/26.
Failure to Report Resident Burn to State Agency
Penalty
Summary
The facility failed to report an unusual occurrence to the State Agency after a resident with metabolic encephalopathy and vascular dementia sustained burns when hot coffee spilled into her lap. The resident’s MDS indicated severe cognitive impairment and that she required supervision for eating. Nursing notes documented that a CNA brought the resident back from the dining room after the spill, and the resident was noted to have redness with fluid-filled blisters to the groin and bilateral thigh area with mild discomfort. The resident’s responsible party requested transfer to the ER for treatment and evaluation. The ER record documented that the resident presented for a burn obtained when she had been drinking coffee and spilled it onto her lap, with partial burns and blistering to the left thigh. Subsequent wound documentation described new wounds as full thickness burns to the bilateral inner upper thighs near the groin region, and the physician later documented burns to both inner thighs requiring ongoing skin surveillance. Orders were written for Silvadene and later for cleansing and dressing changes to both inner thighs. The dietary records showed coffee temperatures were documented at 195 F for breakfast, lunch, and dinner from 1/1/26 through 4/29/26, although the temperature log form directed that coffee be maintained at 150 F to 160 F. During observation, the coffee maker displayed a ready-to-brew temperature of 195 F. The Dietary Manager stated the coffee was supposed to be manually checked with a temperature probe before service, but the temperatures had been recorded from the machine display instead. The Administrator stated the facility did not report the burn to the State Agency because he believed only basic first aid had been required, and he acknowledged the facility did not fully investigate the root cause of the burn.
Failure to Notify Resident’s Representative of New Orders and Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s chosen personal representative of new medical orders and changes in condition, despite the resident’s expressed preference and facility policy requirements. Resident B was admitted with multiple diagnoses, including congestive heart failure, chronic kidney disease stage 3, type 2 diabetes mellitus, and acute metabolic acidosis. An admission MDS assessment documented that the resident was cognitively intact, and a resident preferences evaluation indicated it was very important to the resident to have family or a close friend involved in their care. A Social Services note recorded that the resident wanted her granddaughter to be her emergency contact. However, multiple nursing progress notes over time documented that the resident exhibited chronic confusion. Record review showed that on numerous occasions the facility obtained new medical orders for Resident B without notifying the resident’s personal representative. On one date, new orders were obtained from the nurse practitioner for labs, melatonin, and acetaminophen at bedtime, with no documentation that the representative was notified. On another date, new orders were received for acetaminophen as needed for pain, metformin, lispro insulin, prednisone for COPD, and Robitussin DM for cough, again without notification of the representative. Subsequent physician and nursing notes documented an acute visit for dehydration related to elevated BUN, with orders for IV normal saline, followed by additional orders for IV fluids, Macrobid for a UTI, Keflex for cellulitis of the right leg, and hypodermoclysis for elevated BUN, all without documented notification of the personal representative. Further documentation showed additional new orders and a change in condition for Resident B without representative notification. Nursing notes indicated new orders for furosemide due to excessive fluid seeping from both lower extremities and an increase in Lantus insulin dosage, with no evidence that the personal representative was informed. When the resident complained of chest pain, a new order for nitroglycerin as needed was obtained and administered, and a subsequent order for a two-view chest X-ray was received; in both instances, there was no documentation that the personal representative was notified of the change in condition or the new orders. During interview, the resident’s emergency contact stated she had not been informed of her grandmother’s changes in condition or new orders and noted the resident had periods of confusion and would not understand the orders. The facility’s own Notification of Change policy required informing the resident, consulting the physician, and notifying the resident’s representative when treatment is altered, including new treatment, and specified that even competent residents’ representatives should be notified of significant health status changes, which did not occur in this case.
Failure to Follow Physician Orders for Antihypertensive Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s orders for administration of an antihypertensive medication for one resident. Record review showed that a cognitively intact resident with diagnoses including congestive heart failure, chronic kidney disease stage 3, type 2 diabetes mellitus, and acute metabolic acidosis had a physician’s order for metoprolol 25 mg twice daily for hypertension, with instructions to hold the medication if systolic blood pressure was less than 110 mm/Hg or pulse was less than 60 beats per minute. The Medication Administration Records for November and December 2025 documented that nursing staff administered metoprolol on multiple occasions when the resident’s systolic blood pressure was below the ordered hold parameter, including readings of 102/42 mm/Hg, 102/80 mm/Hg, and 104/73 mm/Hg. During interview, the Assistant Director of Nursing acknowledged that nursing staff should have followed the physician’s orders, and the facility’s policy on Provisions of Physician Ordered Services stated that physician-ordered services are to be provided according to professional standards of quality. This citation relates to Intake 27044933,1-37.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A resident with multiple diagnoses, including multiple sclerosis, mild cognitive impairment, depression, epilepsy, anxiety, and mood disorder, was involved in an incident where a certified nursing assistant (CNA) responded to the resident's call light. The resident, who used a motorized wheelchair independently but required assistance for transfers, toileting, and bathing, was reported to have run over the CNA's foot with her wheelchair. Following this, the CNA was observed and heard screaming as she exited the resident's room. A verbal altercation ensued between the CNA and the resident, requiring intervention from multiple staff members to de-escalate the situation. During the incident, the resident alleged that the CNA hit her in the throat and pushed her into her chair. A physical assessment of the resident revealed no visible injuries, though she complained of neck pain. The incident was documented in the clinical record and reported to the appropriate authorities, including the local police and state health department. The facility's policy prohibits all forms of abuse, including verbal abuse, but the CNA was found to have raised her voice at the resident during the altercation.
Expired Food Found in Kitchen Walk-In Cooler
Penalty
Summary
The facility failed to dispose of expired foods in a timely manner in the main kitchen walk-in cooler. During an initial tour of the kitchen, surveyors observed a container of corn dated 7/29/2025 with a use-by date of 7/31/2025, a container of chicken dated 7/3/2025, 7 individualized cartons of yogurt in a cardboard box with a use-by date of 8/1/2025, a serving bin with ice containing 2 outdated yogurts, and 6 one-half gallon jugs of lime juice with a use-by date of 7/14/2025. During an observation and interview with the Regional Certified Dietary Manager, she indicated the foods should have been disposed within the expiration dates. The report states this deficient practice had the potential to affect 112 of 114 residents who consumed food from the kitchen. The facility policy provided during the survey stated that refrigerated ready-to-eat time/temperature control for safety food shall be held at 41 degrees Fahrenheit or less for a maximum of 7 days, must be clearly marked with the discard date, and that the Head Cook or designee is responsible for checking the refrigerator daily for expiring items and discarding them accordingly.
Unclean and Infested Resident Areas
Penalty
Summary
The facility failed to maintain a clean, sanitary, and comfortable environment on the 400 hall and 500 hall. During observation and interview, Resident 56 reported gnats and flies in her room for the past 2-3 weeks, and the wall by her bed had dark colored liquid speck marks while the privacy curtains were stained with dark specks. Several live flies were also observed in another room, and Resident 95 stated she still had flies in her room and said, "We have them (flies) bad." In Resident 87's room, the wall behind the bed was gouged and had black scuff marks. On the memory care unit, several fruit flies were seen throughout the unit, and Resident 77 stated the flies were in his room and everyone else's. In Resident 3's room, a foam fall mat had dark circular stained areas, the window blind was broken in numerous places, and the trim around the window was cracked in two places. Several flies were noted on Resident 17's bed linens. During a tour with the Administrator, flies were observed in the hallway leading to the 400 hall, a room floor smelled of urine and was sticky, the 500 hall shower room had dead bugs in the sink and gnats flying around the sink with equipment stored in the tub and dried brown substance in the tub and on a bedside commode bucket, and the 400 hall lounge had food crumbs, cobwebs, a dried dark substance, bed linens, and an empty snack bag on the floor.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that 2 of 6 residents reviewed for medications were free from unnecessary psychotropic medications. For one resident, the closed record showed diagnoses including a left femur fracture, diabetes, end stage renal disease, depression, and anxiety, and the medication orders included olanzapine 5 mg at bedtime for depression. During interview, the DON stated that depression was not an appropriate diagnosis for olanzapine and that there was no other diagnosis or medical symptom to support its use for that resident. For another resident, the record showed diagnoses including anxiety disorder and dementia, and a physician's order for lorazepam 0.5 mg by mouth as needed for anxiety and agitation. The resident's electronic medical record lacked documentation from the physician supporting the use of the antianxiety medication beyond 14 days. During interview, the DON stated the resident should not have been on lorazepam for greater than 14 days. The facility policy stated psychotropic medications must be used only for a specific, diagnosed, and documented condition, and PRN psychotropic orders excluding antipsychotics are limited to no more than 14 days unless the prescriber documents the rationale for extending the order.
Delayed Wound Care Planning and Non-Person-Centered PTSD Care Plan
Penalty
Summary
The facility failed to ensure a care plan related to a pressure ulcer was initiated timely for Resident 7. Resident 7 had diagnoses including cardiac arrest, ischemia of the lower extremity with left leg gangrene and amputation, right leg extensive debridement with resulting foot drop, cardiomyopathy, sarcoidosis of the heart, type 2 diabetes, atrial fibrillation, and sleep apnea. A weekly skin check on 4/23/25 identified a new unstageable deep tissue injury on the right lateral forefoot near the 5th digit, measuring 0.4 cm wide by 1.6 cm deep. The wound was followed by physician evaluation, ongoing topical treatments, a wound clinic referral, and nutritional support orders, but the care plan for the wound was not created until 6/12/25. The DON stated during interview that the care plan should have been created when the wound was identified in April. The facility also failed to ensure the comprehensive care plan for Resident 46’s post-traumatic stress disorder included personalized interventions. Resident 46 had diagnoses including post-traumatic stress disorder, behavioral disturbance, and personal history of adult physical and sexual abuse and childhood abuse. The existing care plan included general interventions such as redirection, step-by-step instructions, and visual and verbal cues during care, but it did not include person-centered interventions. An LPN stated that loud noises and overstimulation were triggers for the resident’s PTSD and that one-on-one time, offering drinks or snacks, and moving the resident to a new area were interventions that worked for the resident, but these were not reflected in the care plan.
Failure to Follow Medication and Blood Glucose Orders
Penalty
Summary
The facility failed to follow physician orders for blood pressure medications and insulin-related blood glucose management for multiple residents. For Resident 87, who had end stage renal disease, orthostatic hypotension, hypertension, and aortic valve stenosis, Midodrine was administered on multiple occasions when the documented systolic blood pressure was above the ordered hold parameters. The record showed the medication was given even when systolic blood pressures were documented at 126, 104, 121, 107, 133, 134, 126, 102, 111, 108, 117, 104, 114, 124, and 120 mmHg, despite orders to hold the medication when systolic blood pressure was greater than 100 mmHg on the earlier order and greater than 110 mmHg on the later order. The DON stated the medication should have been held when blood pressure was out of parameters. For Resident 122, who had COPD, type 2 diabetes, CKD stage 3, CHF, atrial fibrillation, and other diagnoses, a Midodrine order was written with a hold parameter using the symbol "<" for systolic BP. The MAR showed Midodrine was administered when blood pressures were 104/52, 121/56, 108/60, 102/64, 96/53, 90/50, 90/51, 93/58, 109/75, 98/54, 97/58, 98/60, 96/66, 95/66, and other values below 110. The DON reviewed the record and stated the incorrect use of the "<" symbol caused the inconsistency and that the symbol should have been ">". The DON also stated the facility did not have a policy regarding the use of symbols in charting. For Resident 2, who had type 2 diabetes, moderate cognitive impairment, borderline intellectual functioning, and schizophrenia, a blood glucose reading of 563 mg/dL was reported to the on-call PA. The PA ordered a one-time dose of 16 units of Lispro, ensured dinner intake, oral fluids, and a repeat blood sugar in one hour with further notification if the blood sugar remained above 450 mg/dL. The record did not show documentation that the ordered Lispro dose was given or that the blood sugar was rechecked one hour later, and the DON confirmed the orders were not documented as completed. For Resident 53 and Resident 13, the MARs showed repeated administration of Propranolol and Midodrine despite documented blood pressures and heart rates outside the ordered hold parameters. Resident 53 received Propranolol when systolic blood pressure was below 110 and when heart rate was 56 bpm, and received Midodrine when systolic blood pressures were above the ordered limit of 120 mmHg. Resident 13 received Midodrine when systolic blood pressures were at or above the ordered hold threshold of 125 mmHg. The DON stated these residents should not have been receiving the medications when vital signs were outside the ordered parameters.
Failure to Implement Hand Orthosis Use for Resident With Hemiplegia
Penalty
Summary
The facility failed to ensure interventions were implemented to prevent contractures for one resident with hemiplegia and impaired range of motion. The resident was cognitively intact, dependent for bed mobility and transfers, and had a physician’s order dated 3/12/2025 directing staff to place a hand orthosis on in the morning and remove it at bedtime. During an observation and interview on 8/5/2025, the resident stated she had an orthosis for her left hand but did not know where it was located in her room, and she was not wearing any orthosis on her left hand. During multiple observations on 8/6/2025, 8/7/2025, 8/8/2025, and 8/12/2025, the resident was lying in bed with her left hand in a fisted position and did not have an orthosis in place. The occupational therapy discharge summary noted the resident had been tolerating the hand orthosis during the day with removal at night, but a nursing progress note documented upper and lower extremity impairment due to hemiplegia and extensive assistance needs. There was no care plan addressing the resident’s hemiplegia or orthosis use, and staff interviews indicated the orthosis had not been worn recently or was used only when the resident was out of bed in her wheelchair, even though she was observed in bed during the survey. The DON stated a policy for orthosis use or range of motion was not available.
Medication Availability and Antipsychotic Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure medications were available and administered as ordered for a resident with diabetes, a kidney transplant, epilepsy, atrial fibrillation, GERD, and depression. For this resident, Apixaban 5 mg twice daily, Pantoprazole 40 mg twice daily, Pregabalin 50 mg daily, and Glipizide 10 mg daily were ordered, but nursing notes documented that Apixaban, Pantoprazole, Pregabalin, and Glipizide were unavailable at various times and were not administered. The record also showed repeated notes that Pregabalin was awaiting pharmacy delivery or on order. The DON later provided a list of emergency medications that included Eliquis 5 mg tablets, Pantoprazole 40 mg tablets, Pregabalin 50 mg tablets, and Glipizide 5 mg tablets, and stated the medications should have been pulled from the emergency drug supply and administered as ordered. The facility also failed to ensure a resident receiving antipsychotic medication was assessed for potential adverse side effects. The resident had diagnoses including dementia with agitation, delirium due to a known physiological condition, and generalized anxiety disorder. Physician orders showed ongoing use of Seroquel or quetiapine fumarate at bedtime from December 2024 through July 2025. Only one AIMS assessment was found in the past 12 months, dated 6/23/2025. The DON stated the resident should have had more than one AIMS assessment in the last 12 months and that there was no other documentation showing the resident had been assessed for adverse side effects related to antipsychotic use.
Failure to Report Alleged Abuse Timely
Penalty
Summary
The facility failed to adhere to its policy regarding the timely reporting of an allegation of abuse involving a resident, identified as Resident B. Resident B reported that during a night the previous week, an employee, referred to as Employee 3, entered her room to assist with changing her brief and made inappropriate comments about the odor. Employee 3 allegedly sprayed Resident B's buttocks with room deodorizer and then inserted the spray can into her rectum. Resident B reported this incident to another employee, Employee 6, on January 20, 2025, while in the facility's lobby. However, Employee 6 did not report the allegation to the Administrator immediately, as required by the facility's policy. The Administrator became aware of the allegation only on January 22, 2025, when informed by Employee 2. Upon learning of the incident, the Administrator suspended Employee 3, reported the allegation to the State Agency, and initiated an investigation. The facility's policy mandates that all allegations of abuse be reported to the Administrator and other relevant authorities within two hours if the events involve abuse or result in serious bodily injury. Employee 6 acknowledged the failure to report the allegation immediately, despite having been trained on the requirement to do so.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, affecting 110 out of 120 residents who consumed meals from the main kitchen. During a meal observation, it was noted that the temperatures of hot foods on the steam table were below the required levels, with pureed corn at 105°F, cream corn at 123°F, pureed beef at 118°F, beef gravy at 128°F, and pepper steak at 123°F. The facility's policy requires hot foods to be maintained at or above 135°F. Additionally, when meals were transported to the 500 hall on non-insulated carts, the last tray served had significantly lower temperatures, with pepper steak at 80°F, sweet potatoes at 85°F, and whole corn at 85°F. Interviews with staff and residents further highlighted the issue. A staff member confirmed that hot food temperatures should be held at or above 140°F while on the steam table, and the Dietary Manager stated that hot foods should be checked and maintained at at least 135°F. Residents expressed dissatisfaction, indicating that the hot food was often served cold. The Administrator acknowledged that hot foods should be served at appropriate temperatures. The Director of Nursing provided the facility's policy, which emphasizes the importance of maintaining proper food temperatures throughout meal service.
Food Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper handling and storage of food, which had the potential to affect 114 out of 115 residents receiving meals from the kitchen. During an initial walkthrough of the kitchen, several issues were observed, including an opened and undated box of lasagna noodles, a gallon of vanilla with an opened date from over a year ago, an undated container of gravy, expired health shakes, and an opened and undated box of Cream of Wheat cereal. These observations indicate a lack of adherence to the facility's policy on date marking for food safety, which requires food to be clearly marked with the date it was opened and the date by which it should be consumed or discarded. Additionally, during meal observations, staff members were seen handling food and meal trays inappropriately. One CNA was observed with her thumb extending over the plate's rim onto the food surface while serving residents, and another CNA was seen carrying a meal tray on her shoulder, allowing her hair to touch the top of the tray. These actions demonstrate a failure to follow proper food handling procedures, which could compromise the safety and hygiene of the meals served to residents. The facility's inability to provide a policy on meal tray delivery further highlights the lack of proper guidelines and training for staff in this area.
Deficiency in Resident Fund Access
Penalty
Summary
The facility failed to ensure that resident funds were available on the same day of the request and for the desired amount for four residents whose personal funds were managed by the facility. Residents reported limited access to their funds, with availability restricted to weekdays between 9 A.M. and 4 P.M., and no access on weekends. Additionally, residents were informed of a five-dollar withdrawal limit, which was not in accordance with facility policy. Interviews with staff revealed a lack of awareness regarding the withdrawal limit imposed on residents. The Business Office Manager indicated that there should not be a five-dollar withdrawal limit, and the Executive Director was unaware that staff were communicating this limit to residents. The facility's policy stated that during non-business hours, the Business Office Manager or a designee should provide the Nurse Supervisor with a petty cash box for resident funds, but this procedure was not effectively implemented.
Insufficient Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to ensure that the surety bond covering the Resident Fund account was sufficient to cover the total amount of funds held. During a review of the Resident Fund accounts with the Business Office Manager and the Executive Director, it was found that the total amount in the accounts was $286,128.00, which was higher than usual due to a closed account with funds from a home sale. The facility's surety bond, however, was only set at $250,000, which was insufficient to cover the total amount. The Executive Director was unaware of why the Corporation had not increased the surety bond amount, despite the facility's policy requiring the bond to be equal to or greater than the total amount of residents' funds as of the most recent quarter.
Failure to Timely Initiate Baseline Care Plans for Residents
Penalty
Summary
The facility failed to ensure timely initiation and completion of baseline care plans for four residents with specific medical needs. Resident 36, who was receiving dialysis, had a baseline care plan that lacked goals, interventions, and special needs, despite being admitted with conditions such as end-stage renal disease and diabetes. The Director of Nursing acknowledged that the care plan did not include all necessary information from the resident's chart. Resident 107, who was on tube feeding due to conditions like cerebral infarction and diabetes, had a care plan that was not completed until several days after admission, contrary to the facility's policy of completing such plans within 48 hours. Similarly, Resident 14, who had a history of falls and multiple health issues including major depressive disorder and heart disease, had a baseline care plan completed late. The Director of Nursing confirmed that the care plan should have been completed within the required timeframe. Resident 99, admitted with a pressure ulcer and moderate cognitive impairment, also did not have a timely baseline care plan for wound care. The facility's policy, which mandates the development of a baseline care plan within 48 hours of admission, was not adhered to in these cases, as confirmed by the Executive Director.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific medical and psychosocial needs. Resident 28, diagnosed with conditions including hemiplegia, dementia, and anxiety disorder, was prescribed Zyprexa for agitation. However, the care plan lacked individualized interventions for managing behaviors associated with antipsychotic use. Interviews revealed that interventions were not tailored to the resident's needs, as they were standardized across all residents. Resident 10, with Alzheimer's disease and other cognitive impairments, reported impaired vision and issues with her eyeglasses. Despite this, her care plan did not address her vision needs, and the MDS inaccurately recorded her vision status. Observations confirmed the presence of prescription eyeglasses, which the resident was not using due to ineffectiveness. The MDS coordinator acknowledged the oversight in the care plan and MDS documentation. Other residents also experienced deficiencies in care planning. Resident 14, with edema in his lower extremities, lacked a specific care plan to monitor and manage this condition, despite being prescribed Lasix. Resident 66, diagnosed with a UTI, did not have a care plan addressing this infection. Similarly, Resident 215, who had not had a bowel movement in 14 days, lacked a care plan for constipation. The Director of Nursing confirmed the absence of necessary care plans for these conditions, contrary to the facility's policy on comprehensive care planning.
Failure to Accurately Document Resuscitative Wishes
Penalty
Summary
The facility failed to provide accurate orders for resuscitative wishes for two residents, leading to a deficiency in honoring residents' rights to formulate and have their advanced directives respected. For Resident 94, there was a discrepancy between the Physician Orders for Scope of Treatment (POST) form, which indicated a do not resuscitate (DNR) status, and the physician's order and care plan, which both indicated a full code status. This inconsistency was confirmed during an interview with an LPN, who acknowledged the conflict between the POST form and the other documents. For Resident 36, the facility failed to document the resident's code status preferences in the physician's orders for the specified period. An LPN confirmed that there should have been an order for the resident's code status. The facility's policy on communication of code status, which was provided by the Director of Nursing, requires that any orders related to a resident's advanced directives be clearly documented in designated sections of the medical record. However, this policy was not adhered to in the case of Resident 36, resulting in a lack of documentation for the resident's code status.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities for a resident who was observed multiple times lying in bed without any music or television playing, despite documented preferences for easy listening music and specific television programs. The resident, who had diagnoses including unspecified sequelae of cerebral infarction, anoxic brain, and tracheostomy, was noted to be unresponsive, and her cognitive function could not be assessed. An Activity Participation Review and a Progress Note indicated that the resident's family had expressed preferences for music and television, which were not being met. The Activity Director acknowledged the absence of a television in the resident's room, which had been removed during a hospital stay, and confirmed that the resident had not received any one-on-one visits since returning from the hospital. The facility's policy on activities emphasized the importance of providing programs that support residents' choices based on their comprehensive assessment, care plan, and preferences. However, the facility did not adhere to this policy, as evidenced by the lack of activities provided to the resident, which were supposed to include television twice daily according to the Activity Tasks for the month.
Failure to Monitor Edema and Timely Administer Antibiotics
Penalty
Summary
The facility failed to monitor edema for a resident who was admitted with significant bilateral edema to his legs and stumps. Despite the resident's condition, the care plans did not include a specific plan to monitor the edema, and assessments did not document the presence of edema. The resident was prescribed Lasix, a diuretic, but there was no policy or procedure in place for monitoring edema, and the documentation was inconsistent. Interviews with staff revealed that the edema was not properly assessed or documented in the clinical records. Additionally, the facility failed to administer antibiotic medication timely for another resident with an infected toe. The resident was prescribed Doxycycline for cellulitis, but the medication order was mishandled, leading to a delay in administration. The first dose was not given until the morning after it was ordered. The facility lacked a policy on the timeliness of following antibiotic orders, and there was no documentation of the medications included in the facility's Emergency Drug Kit.
Failure to Implement Range of Motion Program for Resident
Penalty
Summary
The facility failed to provide a range of motion (ROM) program to prevent further contractures for a resident, identified as Resident 93, who was reviewed for ROM. During an observation, the resident was noted to have her hands in a fist-like position and her knees bent, indicating a lack of proper ROM exercises. A straight-legged, cushioned boot was observed at the end of the resident's bed, suggesting it was not in use. The resident's diagnoses included unspecified sequelae of cerebral infarction, anoxic brain, and tracheostomy, and she was in a persistent vegetative state. Past physician's orders had included the use of a resting hand splint, a foot brace, and passive ROM exercises for the resident's upper and lower extremities every shift. Despite these orders, there was no documentation to confirm that the passive ROM program was being implemented. An LPN indicated that the resident should have been receiving a passive ROM program and acknowledged that the resident's hands and knees were tight. The LPN also mentioned that the resident's splints were discontinued due to causing anxiety. The facility's policy on the prevention of decline in ROM emphasized the need for a systemic approach to prevent ROM decline, including assessment, care planning, and preventative care, which was not adhered to in this case.
Failure to Maintain PICC Line Dressing
Penalty
Summary
The facility failed to provide appropriate care for a peripherally inserted central catheter (PICC) for a resident, identified as Resident 266, who was receiving intravenous medications, vancomycin and piperacillin. On multiple occasions, the PICC line's transparent dressing was observed to be improperly maintained. On July 29, 2024, the dressing was folded in half, leaving the insertion site exposed, and this condition persisted throughout the day. By August 1, 2024, the dressing was not adhered along the lateral edges, and the resident reported that it had become wet during a shower the previous evening. The resident had significant medical conditions, including osteomyelitis, methicillin-susceptible staphylococcus aureus, and type 1 diabetes mellitus, which necessitated careful infection control practices. A physician's order dated July 26, 2024, required the PICC line dressing to be changed weekly and as needed during the night shift. However, an LPN acknowledged seeing the compromised dressing on July 29, 2024, and indicated it was not changed until the following night shift. The facility's policy, provided by the Director of Nursing, stipulated that dressings should be changed weekly or if soiled to minimize infection risk, but this was not adhered to in the case of Resident 266.
Inadequate Tracheostomy Care for Resident
Penalty
Summary
The facility failed to provide adequate tracheostomy care for a resident, identified as Resident 93, who required respiratory support. During observations, the resident's oxygen collar was repeatedly found misaligned, positioned to the left of the tracheostomy stoma site, which affected the resident's oxygen saturation levels. At one point, the oxygen saturation was recorded at 85-86 percent, which is below the physician's order to maintain levels above 90 percent. The resident's condition improved to 92 percent after repositioning, indicating the misalignment of the oxygen collar was impacting respiratory function. A review of the resident's records revealed that the physician's orders for tracheostomy care were incomplete, lacking instructions for changing suction canisters and tubing, tracheostomy ties, and routine tracheostomy care. Additionally, the Medication and Treatment Administration Record for July 2024 showed no entries for tracheostomy care, despite the resident's care plan indicating the need for daily tracheostomy care and monitoring. Interviews with staff confirmed that the necessary orders for comprehensive tracheostomy care were not in place, and the facility's policy emphasized the need for care consistent with professional standards and the resident's care plan.
Failure to Verify Controlled Substance Counts
Penalty
Summary
The facility failed to verify controlled substance counts for a medication cart in the SW Unit. During an observation, it was noted that the controlled medication log book had missing signatures for the count sheets on several dates in July. This indicates that the required verification by the oncoming and offgoing nurse or QMA was not completed. The Director of Nursing confirmed that all narcotic count sheets should be signed for verification of residents' medications. The facility's policy requires two licensed nurses to account for all controlled substances and access keys at the end of each shift, which was not adhered to in this instance.
Inappropriate Antipsychotic Prescription Without Diagnosis
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for a resident who was prescribed an antipsychotic medication, Zyprexa (Olanzapine), for dementia with agitation. The resident's medical record, reviewed on July 31, 2024, included diagnoses such as hemiplegia, cerebral infarction, unspecified dementia, atrial fibrillation, cardiomegaly, hypertension, and anxiety disorder. However, the psychiatric note dated July 24, 2024, lacked an approved diagnosis for the use of Zyprexa and documented a plan to continue the medication despite it being clinically contraindicated, as the benefits were deemed to outweigh the risks. During an interview on August 2, 2024, the Director of Nursing (DON) acknowledged that the resident did not have an appropriate diagnosis for taking the antipsychotic. The facility's policy, titled 'Unnecessary Drugs - Without Adequate Indication for Use,' dated February 2023, was provided by the DON on August 5, 2024. This policy indicated that documentation should be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed. The failure to adhere to this policy resulted in the deficiency noted by the surveyors.
Inadequate Infection Control During Personal Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during personal care for a resident. During an observation, a resident was found lying on wet bed linens and expressed dissatisfaction with the cleanliness of their care. On another occasion, a CNA responded to the resident's call light and noted a strong urine smell in the room, indicating uncertainty about when the resident was last checked or changed. This suggests a lack of timely and adequate personal care for the resident. Further observation revealed that a CNA did not follow proper hand hygiene and glove-changing protocols while providing perineal care. The CNA used the same gloves throughout the process, including when handling soiled items and touching clean linens, without washing hands or changing gloves. The facility's hand hygiene policy, which requires hand hygiene before and after glove use, was not adhered to. The CNA acknowledged the failure to change gloves and wash hands during an interview.
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 481 citations issued within 25 miles in the last 12 months — including the 5 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 Elkhart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Healthcare Center | 0.7 mi | ★★★★★ | 2 | 1 |
| Elkhart Meadows | 1.1 mi | ★★★★★ | 4 | 0 |
| Riverside Village | 1.3 mi | ★★★★★ | 8 | 0 |
| Hubbard Hill Estates Inc | 1.7 mi | ★★★★★ | 2 | 0 |
| Woodland Manor | 1.9 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Brickyard Healthcare - Elkhart Care Center.
100% money-back within 48 hours.
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.