Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 - Laporte Care Center during CMS and state inspections, most recent first.
A resident received Seroquel 100 mg twice daily for anxiety disorder/agitation, but the record did not show an approved diagnosis for the antipsychotic. The resident was cognitively intact, psychiatry was ordered but not completed, and the DON stated there was no approved diagnosis for the Seroquel use.
Failure to provide timely incontinence care: A cognitively intact resident who was dependent for toileting and frequently incontinent of bladder was found wet and saturated with urine after not being checked or changed for hours. The CNA stated she had not checked or changed the resident since the start of her shift, and the DON stated the resident was to be checked and/or changed at least every two hours.
A resident with constipation, opioid use, and bowel management orders had repeated gaps in bowel movement documentation without nursing awareness of the pattern, and the resident’s gluteal cleft wound was observed exposed when the dressing had shifted and become wet with urine. Two other residents had skin findings that were not documented or assessed: one had bruising on the forearm with no care plan or charted bruising, and another had two knee lesions with no prior assessment in the record.
Failure to use a smoking apron as care planned. A resident with COPD who was cognitively intact was observed smoking outdoors without the apron, despite an assessment noting lethargy, falling asleep easily during tasks, and prior burns to clothing, skin, furniture, or other. Later, burn holes were found in the cushion of the resident’s wheelchair. The care plan and smoking safety assessment both directed use of a smoking apron, and the RN consultant stated she had been made aware the resident was not using one.
Incorrect oxygen flow rates were observed for three residents receiving respiratory support. One resident with a trach was on oxygen at 4 L/min even though the order specified 2 L/min with 28% humidification via trach mask, while two other residents were observed on nasal cannula oxygen at 2.5 L/min and 4.5 L/min despite orders for 2 L/min and 4 L/min, respectively. Staff interviews confirmed the oxygen was to be set as ordered.
Inaccurate Fluid Restriction Documentation for Dialysis Resident: A resident receiving dialysis with CKD and ESRD stated she was not on a fluid restriction and could drink whatever she wanted, while the chart showed a 1200 mL fluid restriction, Nepro TID, and ProT Gold BID. The MAR documented 240 cc on most shifts, but the recorded amounts did not account for supplements, meals, or bedside water intake, and the DON said she was unaware the resident was receiving Nepro three times daily.
A resident receiving hospice was given PRN morphine even when pain was documented as 0, despite the order limiting use to pain rated 5-10 or SOB. Another resident received scheduled metoprolol without a documented pulse rate, even though the order required holding the dose if pulse was below 60 and the RN consultant stated the pulse should be documented with each dose.
Hand hygiene was not performed after glove removal during a pressure ulcer dressing change for a resident. An LPN/Unit Manager cleaned the wound, reapplied gloves multiple times, and handled wound products without washing hands between glove changes, despite acknowledging the missed hand hygiene and the DON’s policy requiring handwashing after glove removal.
The facility failed to keep the Main Kitchen walk-in freezer in safe operating condition. Surveyors observed a large buildup of ice on the fans, shelves, floor, and door frame, with food covered in thick frost. The Kitchen Manager said the freezer had been icing up for a long time and was scraped out weekly, while the Maintenance Director and Regional Nurse Consultant both acknowledged the issue had been ongoing for months. A later service report described the box as in poor condition with saturated and taped insulation and moisture dropping from the suction elbow.
Surveyors found that the main kitchen had unsanitary conditions, including dried grease on cooking equipment, dirty oven hood vents, accumulated food spillage on PVC pipes under the dish machine, a dirty floor, and rusted ceiling vents in the dish room. The Dietary Food Manager confirmed these areas needed cleaning.
Several residents were found with medications at their bedside and self-administering them without current physician orders or up-to-date assessments. Medications included throat lozenges, eye drops, nebulizer treatments, topical pain medication, and nasal sprays. In some cases, residents were cognitively impaired or had not been assessed for self-administration capability as required by facility policy.
A resident dependent on staff for dressing and with multiple medical conditions was consistently kept in a hospital gown during the day without documented preference, and was not routinely offered pleasure foods at meals despite no NPO order. Staff only provided pleasure foods if requested, and there was no care plan supporting these practices.
A resident's representative raised multiple concerns about the resident's care, including allegations of a bug and bite marks, but staff failed to initiate grievance forms, document specific concerns, or thoroughly investigate and resolve the complaints as required by facility policy.
Three dependent residents with significant medical conditions were repeatedly observed with unshaven facial hair and, in one case, matted hair, despite being reliant on staff for personal hygiene. Documentation did not show that shaving or hair washing was provided as needed, and staff interviews confirmed these care tasks were not consistently performed.
The facility did not ensure timely assessment and treatment for constipation, bruising, and edema in three residents. One resident with severe cognitive impairment and a history of heart failure did not receive PRN bowel medications as ordered despite multiple days without a bowel movement. Another resident on anticoagulants had visible bruising that was not assessed or documented as required. A third resident with chronic kidney disease and heart disease had persistent hand swelling and pitting edema, but there was no ongoing assessment or care plan intervention for the condition.
A resident with multiple medical conditions, severe cognitive impairment, and dependent on staff for personal hygiene was observed multiple times with very long toenails. Despite being on hospice care and receiving regular visits from hospice staff, the resident had not received podiatry services, and staff were aware of the issue but did not ensure toenail care was provided.
A resident with a history of Alzheimer's, stroke, and right side hemiplegia was repeatedly observed in a wheelchair without the required right shoulder arm tray, despite physician orders and care plan directives for its use to support the upper extremity. Staff interviews confirmed the tray was not consistently in place, and there was no documentation of refusals.
Two residents with significant cognitive and physical impairments did not have required fall prevention interventions in place, including keeping the bed in the lowest position and ensuring a floor mat was present as ordered. Despite care plans and physician orders specifying these measures, staff failed to consistently implement them, as confirmed by the DON.
The facility did not consistently document food consumption for three residents with a history of weight loss, despite care plans and physician orders requiring monitoring due to conditions such as cognitive impairment, failure to thrive, malnutrition, and dietary restrictions. Food intake logs were found to have missing entries for multiple meals, and the DON confirmed that documentation should have occurred for each meal.
A resident with a PEG tube and multiple medical conditions was found lying flat in bed while receiving enteral feeding, contrary to care plan and physician orders requiring the head of the bed to be elevated to at least 45 degrees. Staff reported the resident often adjusted the bed position, but the required elevation was not maintained during the feeding.
A resident with a history of amputation, COPD, and acute respiratory failure was observed experiencing significant pain and reported only receiving Tylenol for relief. Despite physician orders for pain management and a care plan requiring detailed pain assessments, there was no documentation of regular pain assessments in the record. The DON confirmed that pain assessments were not being documented due to the removal of the pain assessment form from the EMR system.
A resident with end-stage renal disease and an AV fistula for dialysis did not have their access site assessed and documented every shift as ordered by the physician and required by facility policy. Review of records showed multiple missed assessments over several months, and the DON confirmed that monitoring should have occurred every shift.
Surveyors found that two residents received unnecessary and excessive medications: one received prolonged and overlapping antibiotic therapy despite being on hospice, and another, who was nonverbal and dependent, was given Lorazepam and Morphine Sulfate together on multiple occasions for pain and anxiety. Staff interviews and record reviews confirmed that medication regimens were not adequately monitored or reviewed, resulting in unnecessary drug use.
Medications were left unattended on a medication cart by an LPN, and a resident with COPD and other conditions was found storing and self-administering his own pharmacy-supplied Albuterol and Fluticasone without physician orders or facility evaluation. These actions did not comply with facility policies requiring locked storage and proper authorization for self-administration.
Staff did not follow infection control protocols for two residents, including not wearing required PPE during high-contact care for a resident with a feeding tube under enhanced barrier precautions, and failing to clean multi-use scissors between wound care procedures for a resident with pressure ulcers. Facility policies required these infection prevention measures, but they were not implemented as observed and confirmed by leadership.
The facility failed to maintain sanitary conditions in food preparation and storage areas. A deep fryer was found greasy with food crumbs, and refrigerators in the A-Wing and C-Wing pantries had dried beverage spillage and improperly labeled items. Staff were unaware of the ownership of some items and did not follow labeling policies.
The facility failed to maintain an effective infection control program, with incomplete documentation and mapping of infections, and improper glove use during insulin administration. The Infection Preventionist and an LPN both demonstrated lapses in following established protocols.
A resident with hemiparesis and other medical conditions waited over 30 minutes for assistance because the call light was not within reach. The DON observed the issue and moved the resident's bed to allow access to the call light.
A staff nurse inappropriately used a resident's insulin pen for personal use, violating the resident's right to be free from misappropriation of medication. The incident was reported by a QMA after being witnessed by two CNAs. The resident had type 2 diabetes mellitus and required insulin. The facility suspended the nurse, removed the insulin pen, and conducted an investigation, leading to the nurse's termination.
The facility failed to provide adequate ADL assistance to dependent residents, specifically in nail care and facial hair removal. Multiple residents were observed with unshaven faces and dirty, untrimmed fingernails despite care plans indicating the need for assistance with personal hygiene.
A facility failed to assess and provide devices for a resident with limited range of motion. The resident was observed with her left hand clenched and lying against her chest, and the Director of Nursing was unaware of the limitation. An OT screen confirmed limited range of motion, and the resident was scheduled for therapy.
The facility failed to monitor meal consumption for a resident with a history of weight loss and nutritional risk. The resident experienced significant weight loss, and meal logs showed multiple undocumented meals. The DON confirmed that meal intakes should be documented after every meal.
The facility failed to ensure a newly hired CNA was certified within 120 days of employment. The employee continued to work past the 120-day period without certification due to a misunderstanding by the Payroll Coordinator, who thought the requirement was 120 shifts instead of 120 days.
The facility failed to accurately document weekly skin assessments and nutritional supplements for two residents. One resident had scabs and a rash that were not properly recorded, while another resident received an incorrect dosage of Ensure due to duplicate physician's orders.
Unapproved Diagnosis for Antipsychotic Use
Penalty
Summary
The facility failed to ensure there was an appropriate diagnosis for the use of Seroquel (quetiapine) for one resident reviewed for unnecessary medications. The resident was admitted with diagnoses including heart disease, respiratory failure, type 2 diabetes, asthma, hypertensive kidney disease, chronic kidney disease, high blood pressure, heart failure, anxiety disorder, pulmonary embolism, opioid dependence, and dependence on renal dialysis. The resident’s MDS indicated the resident was cognitively intact and was receiving an antipsychotic medication on a routine basis. A care plan identified antipsychotic therapy related to anxiety disorder, and a hospital history and physical noted the resident was initially started on Seroquel while hospitalized. A medication list identified quetiapine 100 mg twice daily for agitation. A physician’s order directed quetiapine fumarate 100 mg twice daily related to anxiety disorder, and another order indicated psychiatry was to evaluate. The resident received Seroquel as ordered through discharge. A pharmacy recommendation requested an FDA-approved diagnosis for quetiapine 100 mg twice daily for anxiety disorder, and the NP later signed the recommendation with diagnoses of restlessness and agitation. During interviews, the Regional Nurse Consultant stated the resident refused psychiatry services, and the DON stated the resident never saw the psychiatric NP and there was no approved diagnosis for the use of Seroquel.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a dependent resident received incontinence care and was checked and/or changed at least every two hours. Resident 30 was cognitively intact for daily decision making, dependent on staff for toileting, frequently incontinent of bladder, and had diagnoses including left leg below the knee amputation, COPD, obesity, opioid dependence, bipolar disorder, anxiety disorder, high blood pressure, and chronic pain. The 4/23/26 Quarterly MDS assessment documented the resident’s dependence for toileting, and the CNA task section of the EMR showed incontinence care was documented only twice a day on multiple dates in April and May 2026. During an interview, Resident 30 stated she had not been changed since 12:30 a.m. When CNA 2 and CNA 3 entered the room, CNA 2 stated she had not checked or changed the resident since her shift began at 6:30 a.m. The resident was observed lying on a bed sheet and incontinence pad while wearing an incontinence brief; the pad had a large dried dark brown urine ring all the way around it, the bed sheets were wet up to the resident’s back, and the brief was saturated with urine. CNA 2 stated there was a problem on the midnight shift with a CNA who did not want to change the resident. The DON later stated the resident was to be checked and/or changed at least every two hours.
Failure to manage constipation and assess skin conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for a resident with constipation. Resident 30 was cognitively intact, dependent on staff for toileting, frequently incontinent of bowel and bladder, and receiving opioid medication. The care plan identified a potential for constipation related to pain and set a goal for a normal bowel movement at least every three days, with bowel management to follow the facility bowel protocol. However, CNA documentation showed multiple stretches with no bowel movement for several days at a time, and there was no nursing documentation showing staff were aware the resident had gone longer than three days without a bowel movement or that the resident’s normal bowel pattern was longer than three days. The same resident also had a gluteal cleft wound that was not properly covered during incontinence care. During observation, the resident’s bed linens and incontinence brief were saturated with urine, and the bandage over the upper left hip area had moved and was wet with urine, leaving the open area below the sacrum in the buttock crease exposed. The wound was described as red with a small amount of drainage. The record showed an order to cleanse the gluteal cleft, apply betadine, and cover with bordered gauze daily and as needed, and the NP wound assessment later described a full thickness abscess to the gluteal cleft with moderate drainage. The facility also failed to assess and monitor bruises and skin lesions for other residents. Resident 68 was observed with dark red and purple areas on the left forearm and stated the bruises occurred because the resident kept bumping the arms on the wheelchair and needed a bigger wheelchair, but the record contained no care plan for bruising and no documentation that the bruises were present. Resident 65 was observed with two round skin lesions on the left knee that the resident said came from scraping the knee on the underside of the overbed table, yet the record lacked documentation or prior assessment of the lesions. The DON stated she was unaware of the bruising for Resident 68, and the regional nurse consultant stated the wound nurse would look at Resident 65’s knee again.
Failure to Use Smoking Apron as Care Planned
Penalty
Summary
The facility failed to ensure a resident was using a smoking apron as care planned while smoking. On 5/11/26 at 1:06 p.m., the resident was observed outside in the smoking area with several other residents, the Activity Director, and two other staff members present, and the resident was not wearing a smoking apron. The Activity Director stated the resident did not need a smoking apron. Later that day at 2:49 p.m., the resident was observed seated in his room with his wheelchair in front of him, and there were two burn holes in the wheelchair cushion. The resident’s record showed diagnoses including COPD, and the Quarterly MDS dated 3/16/26 indicated he was cognitively intact. A Smoking and Safety assessment dated 5/6/26 indicated the resident was lethargic and fell asleep easily during tasks or activities, had burned clothing, skin, furniture or other, and recommended use of a smoking apron with staff to light and extinguish smoking material. The Tobacco Use Care Plan dated 5/7/26 also directed use of a smoking apron. During interview, the Regional Nurse Consultant stated she had been made aware the resident was not using a smoking apron.
Incorrect Oxygen Flow Rates Observed for Three Residents
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured when oxygen was observed at incorrect flow rates for 3 of 3 residents reviewed for oxygen. Resident 5 was observed multiple times in bed with a tracheostomy and receiving oxygen by mask over the trach while connected to the room oxygen concentrator set at 4 liters per minute, although the physician's order specified 2 liters per minute with 28% humidification via trach mask while lying in bed. Resident 5's record also showed diagnoses including traumatic subdural hemorrhage, traumatic brain injury, compression of the brain, tracheostomy, and high blood pressure, and the care plan directed oxygen per physician orders and specifically 2 liters per minute with 28% humidification via trach mask. Resident 30 was observed in bed wearing oxygen via nasal cannula at 2.5 liters per minute on multiple occasions, while the physician's order called for continuous oxygen at 2 liters per minute at bedtime and as needed for shortness of breath. Resident 17 was observed in bed wearing oxygen via nasal cannula at 4.5 liters per minute on multiple occasions, although the physician's order specified continuous oxygen at 4 liters per minute. Resident 17's care plan directed oxygen at 4 liters per physician orders, and the resident's record included diagnoses of COPD, heart failure, heart disease, anxiety, and vascular dementia. During interviews, staff indicated the oxygen was to be set as ordered, and the Regional Nurse Consultant stated she had changed Resident 17's oxygen from 4.5 to 4 liters on 5/12/26.
Inaccurate Fluid Restriction Documentation for Dialysis Resident
Penalty
Summary
The facility failed to ensure accurate documentation of a resident’s fluid restriction for a resident receiving dialysis. The resident was admitted with chronic kidney disease, end stage renal disease, and dependence on renal dialysis, and the admission MDS indicated the resident was cognitively intact and received dialysis while in the facility. During interview, the resident stated she was not on a fluid restriction and could drink whatever she wanted, reported receiving apple juice at all three meals, and said she usually drank about 1.5 large styrofoam cups of water each day. The record showed new dialysis physician orders for a 1200 mL fluid restriction, LiquaCel 1 ounce twice daily or an equivalent protein supplement, Nepro with Carb Steady three times daily, and ProT Gold twice daily. The care plan addressed potential fluid volume overload and directed staff to restrict and give fluids per physician order. However, the MAR documented the fluid restriction every shift with amounts of 240 cc on most shifts, which did not reflect intake from Nepro, ProT Gold, meals, or the water the resident drank. The DON stated she was unaware the resident was receiving Nepro three times daily and believed it was only once daily, and there was no documentation of the amount of ProT Gold to be administered or consumed.
Unnecessary opioid administration and missing pulse documentation before beta-blocker doses
Penalty
Summary
The facility failed to ensure that an opioid medication was administered only when it had an indication for use for a resident receiving hospice services. Resident 17 had diagnoses including COPD, heart failure, heart disease, anxiety, and vascular dementia, and the 2/20/26 Quarterly MDS indicated the resident was not cognitively intact for daily decision making and received hospice while a resident. A physician’s order dated 1/28/26 directed Morphine Sulfate Oral Solution 20 mg/5 ml, 0.25 ml by mouth every 1 hour as needed for pain rated 5-10 or shortness of breath, but the 1/2026, 3/2026, and 4/2026 MARs showed the morphine was administered when the resident’s pain rating was 0 on multiple occasions, including 1/15, 1/25, 3/17, 3/21, 4/19, and 4/21/26. The facility also failed to ensure a pulse rate was monitored before administering a blood pressure medication for another resident. Resident 65 had diagnoses including diabetes and hypertension, and the 3/25/26 Significant Change MDS indicated the resident was cognitively intact for daily decision making. A physician’s order dated 5/1/25 directed Metoprolol Tartrate twice daily and to hold the medication for a pulse rate less than 60, but the resident received the medication without a documented pulse rate on each day from 4/1/26 through 5/12/26. During interview, the Regional Nurse Consultant stated the pulse should be documented with each dose and should have been added to the MAR.
Hand Hygiene Not Performed During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure infection control practices were followed during a pressure ulcer treatment for one resident. During the treatment observation, the Unit Manager gathered supplies, performed hand hygiene, donned PPE, and removed the resident’s sock and old bandage with clean gloves. She then cleaned the pressure ulcer with wound cleaner, patted it dry, removed her gloves, and put on a clean pair of gloves without performing hand hygiene after glove removal. She continued the treatment by opening collagen particles and placing them on the open area with gloved hands, then opened zinc oxide and applied it to the wound and surrounding skin with a gloved finger. She again removed her gloves and donned another clean pair of gloves without performing hand hygiene. She later placed a bordered gauze bandage on the ulcer and then removed her gloves and washed her hands with soap and water. During interview, the Unit Manager stated she was aware she should have performed hand hygiene after glove removal, and the Regional Nurse Consultant also stated hand hygiene should have been performed after glove removal. The facility’s 2025 Clean Dressing Change policy stated to remove gloves, wash hands, and put on clean gloves before continuing wound care.
Walk-In Freezer Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure the Main Kitchen walk-in freezer was kept in safe operating condition. During a tour of the Main Kitchen, a large buildup of ice was observed in the freezer, including ice on the fans, shelves, floor, and door frame, and the food stored on the shelves had a thick layer of frost on it. The Kitchen Manager stated the freezer had been building up ice for a long time and that she would go in about once a week to scrape out the ice. She also said they were waiting to get a new freezer next year. The Maintenance Director stated the freezer had been building up with ice for a long time, had been looked at, but could not be repaired, and would probably be replaced next year. The Regional Nurse Consultant said she was aware of freezer issues for months and that the replacement was being worked into the budget. A later service call report noted the walk-in freezer condenser was inspected, the box was in poor condition with saturated and taped insulation, moisture was dropping from the suction elbow, and a new closer was needed for the condenser.
Unsanitary Kitchen Conditions Due to Unclean Equipment and Surfaces
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the main kitchen, as evidenced by multiple instances of unclean food equipment and areas. Specifically, there was a large amount of dried grease on top of and on the sides of the deep fryer, as well as on the side of the stove and steamer, with additional food crumbs and dust under the steamer. The oven hood vents were found to be dirty and greasy. The white PVC pipes under the dish machine had a significant accumulation of dried food spillage, and the floor beneath the dish machine was dirty with adhered dirt against the wall. Additionally, two rusted ceiling vents were noted in the dish room. During an interview, the Dietary Food Manager acknowledged that all of these areas required cleaning.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and had physician's orders to self-administer medications for four residents reviewed. Multiple observations revealed that medications, including throat lozenges, eye drops, nebulizer treatments, topical pain medication, and nasal sprays, were found in residents' rooms and accessible for self-administration without appropriate documentation or current physician orders. In several cases, medications were left at the bedside or in personal storage, and residents reported using them independently as needed. For one resident with COPD and chronic respiratory failure, a bag of throat lozenges was observed in the room without a physician's order, and the last self-administration assessment was over a year old. Another resident with neurocognitive disorder and cerebral aneurysm had eye drops at the bedside, but there was no order or assessment for self-administration, and the resident was cognitively impaired. A third resident, who was cognitively intact but required partial assistance with ADLs, had a nebulizer, Biofreeze, and Fluticasone in his room, with no orders for self-administration or for the medications to be kept at the bedside, and the assessment did not document capability for topical medication administration. A fourth resident, also cognitively intact but requiring substantial assistance with ADLs, had a nasal spray and topical steroid on the bedside table, with the most recent self-administration assessment being nearly a year old. The facility's policy required interdisciplinary team assessment and physician orders for self-administration, but these procedures were not followed for the residents involved.
Failure to Maintain Resident Dignity and Offer Pleasure Foods
Penalty
Summary
A resident with a history of stroke, hemiplegia, dysphagia, chronic kidney disease, heart failure, and a PEG tube was repeatedly observed wearing a hospital gown during the day, with no documentation indicating this was the resident's preference. The resident was dependent on staff for dressing and personal hygiene and was not cognitively intact for daily decision making, according to the MDS assessment. Despite this, staff consistently dressed the resident in a hospital gown, and there was no care plan addressing this practice or indicating resident preference. Additionally, the resident was not consistently offered pleasure foods during meal times, even though there was no physician's order for nothing by mouth. Observations showed that while the resident's roommate received meal trays, the resident was not offered any food or pleasure items unless specifically requested. Interviews with staff confirmed that pleasure foods were only provided upon request, and the dietary manager stated that food was not routinely sent unless asked for. The DON acknowledged that pleasure foods should be offered at every meal, and there was no care plan supporting the use of a hospital gown during the day.
Failure to Document and Investigate Resident Grievances
Penalty
Summary
The facility failed to properly document, investigate, and resolve grievances raised by a resident's representative regarding the care of a resident with diagnoses including diabetes, a sacral pressure ulcer, colon cancer, and dementia. The resident was cognitively intact and required maximum assistance with activities of daily living and transfers. On two separate occasions, the resident's representative voiced concerns and made accusations about the resident's care, including the presence of a bug and bite marks found during a wound clinic visit. Although these concerns were discussed in meetings and documented in social service notes, there was no documentation of the specific concerns, investigation, or resolution, and a grievance form was not initiated as required by facility policy. During interviews, the Social Services Director acknowledged that no grievance forms had been completed for the concerns raised, despite regular meetings and documentation in progress notes. The facility's policy required staff to record grievances on a designated form and for the Grievance Official to document actions taken toward resolution. The lack of formal grievance documentation and investigation constituted a failure to honor the resident's right to voice grievances without discrimination or reprisal, as well as a failure to follow the facility's established grievance policy.
Failure to Provide Assistance with Shaving and Hair Washing for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three dependent residents, specifically regarding shaving and hair washing. Observations over several days revealed that one resident remained in bed wearing a hospital gown and consistently had a moderate amount of facial hair on her chin. Her records indicated she was not cognitively intact and was dependent on staff for personal hygiene due to a stroke, yet there was no documentation of assistance with facial hair removal. Another resident, who was dependent on staff for personal hygiene due to Parkinson's and Alzheimer's disease, was repeatedly observed with a large amount of facial hair, and there was no documentation that he had been shaved despite regular showers. A third resident, also dependent on staff for personal hygiene, was observed with a large amount of facial hair and matted, knotted hair. Documentation showed he received showers or bed baths twice weekly, but there was no record of shaving or hair washing during this period. Interviews with staff, including the Director of Nursing, confirmed that these residents should have been shaved and had their hair washed as needed, but this care was not consistently provided or documented. The residents involved had significant medical conditions, including stroke, hemiplegia, dysphagia, Parkinson's disease, Alzheimer's disease, and limited mobility, all of which contributed to their dependence on staff for personal hygiene. The lack of assistance with shaving and hair washing for these dependent residents constituted a failure to meet their ADL needs as required.
Failure to Provide Timely Assessment and Treatment for Constipation, Bruising, and Edema
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in several instances. One resident with a history of acute respiratory failure, heart disease, and severe cognitive impairment was at risk for constipation and had physician orders for bowel management, including a PRN bisacodyl suppository. Despite multiple documented periods of no bowel movement, the PRN suppository was not administered, and there was no facility policy for constipation management. The Director of Nursing confirmed that staff should administer PRN medications after three days without a bowel movement or contact the physician if no PRN orders were available. Another resident on anticoagulant therapy with a history of heart failure and diabetes was observed with bruising on the shins and right knee over several days. The care plan required monitoring and documentation of bruising, and physician orders directed staff to observe for signs of bleeding every shift. However, the record lacked documentation of assessments for the bruised areas. Additionally, a resident with chronic kidney disease and heart disease was observed with persistent hand swelling and pitting edema, but the record contained only one assessment and lacked care plan interventions for edema monitoring or treatment. Nursing staff were unaware of the swelling, and the DON acknowledged that regular assessment and documentation were required but not completed.
Failure to Provide Appropriate Foot Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for personal hygiene and was receiving hospice care was repeatedly observed with very long toenails over several days. The resident, who had diagnoses including acute respiratory failure, anxiety, heart disease, osteoarthritis, and heart failure, was severely impaired for decision making and was never or rarely understood, according to the Minimum Data Set assessment. Despite being under hospice care, there was no documentation of podiatrist visits since admission, and hospice had previously determined that podiatry services were not necessary for this resident. Staff, including a QMA and the Wound Nurse, were made aware of the resident's long toenails, and the Director of Nursing confirmed that hospice staff provided regular care, during which the toenails should have been observed.
Failure to Ensure Prescribed Arm Tray Was in Place for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of Alzheimer's disease, stroke, right side hemiplegia, and limited range of motion was observed multiple times sitting in a wheelchair without the prescribed right shoulder arm tray in place. Instead, the resident's right arm was elevated on a small bed pillow. The care plan and physician's order both specified that the resident was to use a right shoulder arm tray to support the right upper extremity while upright in the wheelchair for joint protection and proximal support. Documentation in the Medication Administration Records indicated that the tray was signed out as being on the wheelchair every day shift, with no documented refusals. Interviews with staff revealed that the arm tray was stored between the dresser and nightstand and was supposed to be attached to the wheelchair whenever the resident was up. Staff also noted that the resident's daughter might sometimes request its removal, but there was no documentation of such refusals. The Director of Nursing confirmed that the tray was to be on the resident's wheelchair, indicating a failure to ensure the assistive device was consistently in place as ordered and care planned.
Failure to Implement Fall Prevention Measures for At-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents with a history or risk of falls. For one resident with diagnoses including Parkinson's disease, Alzheimer's disease, and other significant conditions, observations revealed that the bed was not kept in the lowest position as required by the care plan, despite the resident being dependent on staff for transfers and bed mobility. Documentation showed that this resident had previously been found on the floor mat next to the bed, and the Director of Nursing confirmed that the bed should have been in the lowest position. For another resident with multiple diagnoses and severe cognitive impairment, observations showed that a floor mat was not present next to the bed while the resident was in bed, contrary to both the care plan and a physician's order. This resident had a documented history of falls from the bed, and the care plan specifically required a floor mat to be in place at all times while the resident was in bed. The Director of Nursing acknowledged that the mat should have been present. These failures demonstrate that the facility did not ensure required fall prevention measures were consistently implemented for residents at risk.
Failure to Document Food Intake for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were consistently completed for residents with a history of weight loss. For three out of four residents reviewed for nutrition, there were multiple instances where meal intake was not documented as required. This deficiency was identified through observation, record review, and staff interviews. One resident with diagnoses including mild cognitive impairment, adult failure to thrive, and dysphagia had a significant weight loss of 27% over six months. Despite care plans and physician orders addressing her nutritional needs, her food consumption logs had missing entries for several meals throughout the month. Another resident, who had a history of stroke, congestive heart failure, and dependence on renal dialysis, experienced a 12% weight loss in one month following hospitalization. His care plan required monitoring due to dietary restrictions and fluctuating intake, yet his dinner intake was not documented on multiple occasions. A third resident, diagnosed with neurocognitive disorder, protein-calorie malnutrition, and dysphagia, was also identified as being at nutritional risk. Her care plan included interventions to monitor and record meal intake at every meal, but her logs showed missing documentation for several lunches and dinners. In each case, the DON confirmed that food consumption should have been documented for every meal, but this was not consistently done.
Failure to Maintain Proper Bed Elevation During Tube Feeding
Penalty
Summary
A deficiency occurred when a resident receiving enteral nutrition via a PEG tube was observed lying completely flat in bed while tube feeding was actively infusing at 55 cc per hour. The head of the bed was not elevated to at least 45 degrees as required by the resident's care plan and physician's orders. Staff interviews revealed that the resident frequently adjusted the bed position using the remote control, and the head of the bed had been elevated earlier during medication administration, but was found flat during the observation. The resident involved had a history of stroke, hemiplegia, dysphagia, chronic kidney disease, heart failure, and a cardiac pacemaker, and was not cognitively intact for daily decision making. The care plan specifically directed staff to maintain the head of the bed at a minimum 45-degree elevation during tube feeding. Facility policy also required staff to follow care plan directives regarding resident positioning during enteral feeding. Despite these directives, the required positioning was not maintained at the time of observation.
Failure to Assess and Document Pain Management per Care Plan
Penalty
Summary
A resident with a history of left leg amputation, COPD, and acute respiratory failure with hypoxia was observed wincing in pain while moving in bed and reported daily pain in the shoulder and hip, rating it between 5 and 8 out of 10. The resident stated that only Tylenol was being provided for pain and was unaware of the reason for this approach. Review of the resident's medical record revealed physician orders for both topical Biofreeze and oral acetaminophen for hip pain, as well as a care plan that required monitoring and recording of pain characteristics such as quality, severity, location, onset, duration, aggravating, and relieving factors. Despite these orders and care plan interventions, the record lacked documentation of regular pain assessments. During an interview, the DON acknowledged that pain should be assessed and documented for residents experiencing pain or receiving pain medication, but noted that the facility's EMR system had removed the pain assessment form, leaving them without a current method for documentation. The facility's pain management policy required recognition and management of pain consistent with the comprehensive assessment and plan of care, which was not followed in this instance.
Failure to Consistently Assess and Document Dialysis Access Site
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident requiring dialysis had their dialysis access site assessed and monitored as ordered. The resident, who had diagnoses including stroke, congestive heart failure, and dependence on renal dialysis, had a physician's order for their arteriovenous (AV) fistula to be assessed for patency, audible bruit, and palpable thrill every shift. The care plan also required monitoring and documentation of signs and symptoms of infection at the access site. However, review of the Treatment Administration Records (TAR) for January, February, and March revealed multiple shifts where there was no documentation that the AV fistula was assessed as required. During an interview, the Director of Nursing confirmed that the resident's fistula should have been monitored every shift, in accordance with the facility's hemodialysis policy. The policy specified that the dialysis access site should be checked before and after dialysis treatments and every shift for patency by auscultation and palpation. The lack of documentation on several shifts indicated that the required assessments were not consistently performed or recorded, resulting in noncompliance with physician orders and facility policy.
Failure to Prevent Unnecessary Drug Use and Excessive Medication Regimens
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs, specifically regarding the use of antibiotics and the administration of medications for pain and anxiety. For one resident with a history of ESBL, neurogenic bladder, sepsis, and recurrent UTIs, records showed prolonged and overlapping use of multiple antibiotics, including Macrobid, Zyvox, Meropenem, Levaquin, and Imipenem-Cilastatin. Despite the discontinuation of a Foley catheter and multiple courses of IV antibiotics, the resident continued to receive oral Macrobid concurrently. The Director of Nursing acknowledged that the resident had received numerous rounds of antibiotics and questioned the ongoing effectiveness of the oral antibiotic, especially as the resident was also on hospice care. Another resident, who was severely cognitively impaired, dependent for mobility, and receiving hospice care for multiple diagnoses including acute respiratory failure and heart failure, was administered both opioid and anti-anxiety medications. Medication administration records indicated that Lorazepam and Morphine Sulfate were frequently given simultaneously or within minutes of each other on numerous occasions over several months. Staff relied on nonverbal pain assessment tools due to the resident's inability to communicate pain levels, and the DON confirmed that the two medications should not have been administered together. These findings demonstrate that the facility did not adequately monitor or review the necessity, duration, and dosing of medications for these residents, resulting in the use of unnecessary drugs and potentially excessive medication regimens. The deficiencies were identified through record review and staff interviews, highlighting lapses in medication management and oversight for residents with complex medical needs.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for two residents. In one instance, an LPN was observed preparing medications for a resident and left a medication cup containing two pills and a packaged Tamsulosin tablet on top of the medication cart while entering the resident's room, leaving the cart and medications unattended and out of view. The facility's policy requires all drugs and biologicals to be stored in locked compartments, but this was not followed during the medication administration process. In another case, a resident with a history of COPD, amputation, and acute respiratory failure was found to have a bag in his closet containing multiple boxes of Albuterol and Fluticasone, which he obtained from his own pharmacy and used as he felt necessary. There were no physician orders for the resident to use his own medications or to keep them at bedside, and the facility's policy requires evaluation and specific orders for self-administration and bedside storage. The Director of Nursing was unaware of the resident's possession and use of these medications.
Failure to Implement Infection Control Practices for EBP and Wound Care
Penalty
Summary
Staff failed to implement proper infection control practices for residents under enhanced barrier precautions (EBP) and during wound care procedures. In one instance, a resident with a feeding tube, who had an order for EBP, was observed being repositioned and receiving a bed bath by staff who wore gloves but did not don required isolation gowns. The resident's medical record indicated multiple complex diagnoses, including stroke, hemiplegia, dysphagia, and a PEG tube, and the facility's policy required both gowns and gloves for high-contact care activities for residents with feeding tubes. Despite this, staff did not follow the policy, as confirmed by the absence of used gowns in the room and acknowledgment from facility leadership. In a separate incident, a wound nurse was observed using the same pair of scissors to remove and apply bandages to a resident's pressure ulcers on both feet without cleaning the scissors between uses. The nurse admitted to not cleaning the scissors between dirty and clean bandages or between different wound sites. The resident involved had significant cognitive impairment and two unhealed Stage 2 pressure ulcers. Facility policy required that multi-use equipment be cleaned and disinfected after each use, but this was not followed, as confirmed by the Director of Nursing.
Sanitation Issues in Kitchen and Pantries
Penalty
Summary
The facility failed to ensure food was prepared and stored under sanitary conditions. During a kitchen sanitation tour, a deep fryer was observed to be greasy with many food crumbs, and the grease extended to the side of the convection oven. The Dietary Food Manager indicated that the deep fryer was cleaned weekly. In the A-Wing pantry refrigerator, there was a heavy accumulation of dried pink, orange, and red beverage spillage, and the refrigerator housed residents' food and other beverages. An LPN present during the observation had no comment regarding the spillage. In the C-Wing pantry refrigerator, an open bottle of orange Gatorade with no open date or label was found. An LPN indicated she did not know whose Gatorade it was and speculated it might belong to a resident who recently had a colonoscopy. The facility's policy required food or beverages brought in from outside to be labeled with the resident's name, room number, and the date the item was brought in.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by incomplete documentation and mapping of infections, and improper glove use during insulin administration. The Infection Control Logs for January through April 2024 lacked documentation of diagnostic lab or x-ray results and did not confirm if criteria for a true infection were met. Additionally, several entries lacked documentation of signs or symptoms associated with the infections. The Infection Preventionist admitted to not including infection criteria or diagnostic results on the Infection Log, as she believed the information was available elsewhere in the record. Furthermore, the January and March 2024 infection maps did not accurately reflect the number of residents with urinary tract and respiratory infections, respectively, due to missed entries and carryovers from previous months. This inconsistency was acknowledged by the IP nurse during an interview. Additionally, an LPN was observed administering insulin to a resident without donning gloves, contrary to the facility's policy. The LPN indicated she was unaware that gloves were required during insulin administration. The facility's current policy on insulin pen use clearly states that gloves should be worn during the procedure. This lapse in protocol was observed during a medication pass and highlights a gap in adherence to infection control practices among the staff.
Failure to Ensure Resident Could Reach Call Light
Penalty
Summary
The facility failed to ensure a resident who required staff assistance for activities of daily living (ADLs) received necessary services related to having the ability to reach the call light when ADL care was needed. Resident 32, who had diagnoses including hemiparesis following cerebral infarction, chronic kidney disease, and diverticulosis, indicated he had waited over 30 minutes to get help off the stool and could not reach the call light. Observations confirmed that the call light was not within reach, and the resident smelled of feces. The Director of Nursing (DON) observed the situation and moved the resident's bed to allow the resident to reach the call light. The resident's record indicated he was dependent for toilet assistance and required partial to moderate assistance for toilet transferring.
Misappropriation of Resident's Medication by Staff Nurse
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of medication when a staff nurse used the resident's insulin pen for her personal use. The incident was reported by a Qualified Medication Aide (QMA) to the Director of Nursing (DON) and the Administrator after two Certified Nursing Assistants (CNAs) witnessed the Licensed Practical Nurse (LPN) using the resident's insulin pen on herself. The resident involved had a diagnosis of type 2 diabetes mellitus with diabetic neuropathy and required insulin usage as indicated in their care plan and medication orders. The insulin pen was prescribed to be administered subcutaneously every 12 hours. The facility's policy on abuse, neglect, and exploitation was violated when the LPN used the resident's insulin pen. Immediate action was taken by the facility, including suspending the LPN and removing the insulin pen from the medication cart. The incident was thoroughly investigated, and the LPN was found guilty of misappropriation of medication and subsequently terminated. The facility also conducted staff interviews and reviewed the resident's care plan and medication orders to confirm the deficiency.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate ADL assistance to dependent residents, specifically in the areas of nail care and facial hair removal. Resident 23, who had diagnoses including dementia, high blood pressure, and heart disease, was observed multiple times over several days to be unshaven. Despite receiving hospice services and bed baths twice a week, there was no documentation indicating that the resident had been shaved. The care plan for Resident 23 indicated a need for substantial assistance with personal hygiene, which was not adequately provided as evidenced by the resident's unshaven state during the observations. Resident 45, diagnosed with Alzheimer's dementia and other conditions, was observed with long and dirty fingernails on multiple occasions. The resident's care plan indicated a need for partial to moderate assistance with personal hygiene, and her shower documentation showed she received showers twice a week. However, there was no documentation that her nails were trimmed during these showers. Similarly, Resident 11, who had hemiplegia and mild cognitive impairment, was observed with long and dirty fingernails despite indicating a preference for well-groomed nails. The resident's care plan required dependent assistance for bathing and toileting, yet her nails remained unkempt even after receiving a shower. These observations and records indicate a failure by the facility to provide necessary ADL assistance to these residents.
Failure to Assess and Provide Devices for Limited Range of Motion
Penalty
Summary
The facility failed to ensure an assessment was completed and devices were in place for a resident with limited range of motion. Resident 45 was observed multiple times with her left hand clenched and lying against her chest while sitting in a wheelchair. The Director of Nursing was unaware of the resident's range of motion limitations and no anti-contracture device was in place for the left hand. The resident's record indicated diagnoses including Alzheimer's dementia, high blood pressure, depression, psychotic disorder, and traumatic subdural hemorrhage encounter. The Quarterly Minimum Data Set (MDS) assessment indicated no impairment to her upper extremities, but a Functional and Abilities Assessment showed impairment to one side for both upper and lower extremities. An Occupational Therapy (OT) Plan and Treatment indicated impaired left upper extremity strength, but the shoulder, elbow/forearm, and wrist were within normal limits. On 5/13/24, the Director of Nursing assessed the resident's left hand and found limited extension of the middle finger. The Physician was notified, and a new order was received for OT to evaluate and treat. An OT screen completed the same day indicated a 70-degree flexion at the knuckle with pain indicated by facial expressions and sounds, although the resident denied pain when asked. The Certified Occupational Therapist Assistant confirmed the limited range of motion and indicated the resident would be picked up by OT for therapy.
Failure to Monitor Meal Consumption for Resident at Nutritional Risk
Penalty
Summary
The facility failed to ensure meal consumption was monitored for a resident with a history of weight loss and nutritional risk. Resident 51, who had diagnoses including pneumonia, diabetes, anemia, acute pancreatitis, and anxiety, was noted to have an 8.25% weight loss over 30 days. The resident's care plan indicated the need to observe meal intakes, but meal consumption logs showed multiple instances where meals were not documented. Specifically, breakfast was not documented on two occasions, lunch on five occasions, and dinner on nine occasions. The Director of Nursing confirmed that meal consumption should be documented after every meal.
Failure to Ensure CNA Certification Within 120 Days
Penalty
Summary
The facility failed to ensure that a newly hired Certified Nursing Assistant (CNA) was certified within 120 days of employment. Employee 1 was hired on January 10, 2024, and their 120th day of employment was on May 8, 2024. However, the employee continued to work as a CNA on May 9, 13, and 14, 2024, without the required certification. During an interview, the Payroll Coordinator revealed a misunderstanding, believing the requirement was 120 shifts instead of 120 days. Employee 1 was still working on the floor as a CNA on May 14, 2024, despite not being certified past the 120-day period.
Inaccurate Documentation of Skin Assessments and Nutritional Supplements
Penalty
Summary
The facility failed to ensure clinical records were accurately documented for weekly skin assessments and nutritional supplements for two residents. Resident 16 was observed with many bloody and dried scabs on his upper body, arms, and trunk. Despite this, the weekly skin reviews inaccurately documented his skin as intact on multiple occasions. The Director of Nursing indicated that the nurses might have misunderstood the assessment criteria, leading to incorrect documentation of the resident's skin condition. Resident 51 experienced significant weight loss, dropping from 204 pounds to 189 pounds within 30 days. The resident had physician's orders for Ensure nutritional supplements, but the Medication Administration Record indicated that the resident received four cans of Ensure daily instead of the prescribed two cans. The Director of Nursing acknowledged that nursing staff should have discontinued one of the orders to avoid confusion, resulting in the resident receiving an incorrect dosage of nutritional supplements.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 264 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near La Porte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Terrace Care Center | 0.3 mi | ★★★★★ | 2 | 0 |
| Miller's Health & Rehab By Miller's Merry Manor | 2.5 mi | ★★★★★ | 0 | 0 |
| Aperion Care Arbors Michigan City | 10.5 mi | ★★★★★ | 23 | 1 |
| Life Care Center Of Michigan City | 11.1 mi | ★★★★★ | 9 | 0 |
| Miller's Merry Manor | 13.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.