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 - Merrillville Care Center during CMS and state inspections, most recent first.
Surveyors observed that a nurse prepared and administered Lantus and Novolog insulin to a resident with DM without priming the insulin pens as required by facility policy, despite having physician orders for a specific sliding-scale Lispro (Novolog) dose and a daily Glargine (Lantus) dose. The nurse acknowledged being unsure how to properly prime the pens. This incident occurred during a medication pass in which two errors were identified out of 25 opportunities, resulting in a medication error rate of 8%, exceeding the required threshold of less than 5%.
Surveyors found that multiple made beds on the Advanced Alzheimer’s Care Unit contained visibly soiled linens, including brown stains, food crumbs, and a brown substance on sheets and a pillowcase. An RN supervisor confirmed that four beds had been made without changing dirty linens, while the Administrator reported that staff denied making the beds and suggested residents may have done so, and there was no linen-change policy. The affected residents had severe cognitive impairment, dementia or Alzheimer’s disease, frequent incontinence, and required staff assistance for ADLs, with care plans for several residents not indicating that they made their own beds.
Dishwasher Chemical Sanitizer Testing Not Maintained: The Dietary Service Manager stated the chemical dishwasher was tested during the kitchen tour, but the test strip results were inconsistent and then washed away, and a strip dipped into the solution did not register any ppm reading. Dietary Aides stated they had not tested the solution that day, and the dish machine log showed wash and rinse temperatures recorded while the ppm column was left blank.
Environment Not Kept Clean and in Good Repair: Surveyors observed discolored and stained ceiling tiles, dirty ceiling vents, broken window curtain fasteners in a room with two residents, peeling wallpaper under window sills in a common area, gouges in a wall near the nurses’ station, and marred flooring with black scuff marks in a room with two residents across Reflections, C-wing, and D-wing. The Regional Maintenance Director and Housekeeping Manager stated the conditions needed cleaning and/or repair.
Failure to Document Interventions Before PRN Anti-Anxiety Medications: A resident with Alzheimer's disease, psychotic disorder with delusions, anxiety disorder, and severe cognitive impairment received PRN lorazepam and hydroxyzine for anxiety without documented prior interventions. The MAR showed multiple administrations of both medications, and the DON was unable to provide further documentation; the facility's PRN med policy required documentation of the resident's reason and assessment findings before giving the medication.
A resident with fx of the R femur, RA, and generalized anxiety disorder was receiving anti-anxiety meds, including chlordiazepoxide PRN and clonazepam scheduled, but the record had no care plan for anti-anxiety medication use. The existing care plans for mood, psychotropic meds, and discharge planning did not address the resident’s anxiety meds or related interventions, and the MDS nurse stated an Anti-anxiety Medication Care Plan should be in place.
Failure to provide needed fingernail care. A resident with DM, CHF, OA, and moderate cognitive impairment required substantial assistance with ADLs and was dependent for transfers and toileting, with care plan needs for bathing and personal hygiene assistance. During observations, the resident reported not receiving scheduled showers and stated his fingernails had not been cleaned or cut; dark debris was seen under slightly long fingernails. The MDS nurse stated she would take care of his fingernails.
A resident with an indwelling urinary catheter, neurogenic bladder, and a recent MRSA infection at the suprapubic catheter site was observed in bed with the catheter bag on the floor, and later with both the bag and tubing on the floor. The care plan directed staff to keep the drainage bag below the bladder level and off the floor, and an RN acknowledged the setup was incorrect.
A resident with COPD, respiratory failure, and other diagnoses was observed using portable O2 at different flow rates, including 4 L and 2 L via NC. The chart showed an order for 3 L via NC if O2 sats were below 90% each shift, but the MAR documented 3 L as administered every shift even though sats were above 90%, and there was no documentation stating how much O2 to give when sats were above 90%. RN and the VPRC stated the order needed clarification.
Narcotic and PRN Medication Documentation Errors: A resident with lung cancer and Hodgkin's lymphoma on hospice had a fentanyl patch ordered for pain, but it was not given when due and was later noted as on order or unavailable. PRN morphine sulfate and lorazepam were also inconsistently documented, with MAR entries not matching the narcotic reconciliation sheet, and the DON stated nurses were recording medication use on the reconciliation sheets instead of the MAR.
Medication administration error rate exceeded 5%. During a med pass, an RN crushed multiple medications for a resident, including aspirin enteric-coated and metoprolol ER, and gave them mixed with applesauce. The RN later stated those medications should not have been crushed. The observation resulted in 2 med errors during 27 opportunities, for a 7.41% error rate.
Infection control guidelines were not properly implemented when an RN used the same alcohol wipe to clean an insulin vial and a resident’s abdominal injection site during insulin administration. The facility also lacked physician orders for contact isolation for two residents on transmission-based precautions, including one with MRSA-related treatment and another with C. difficile and ongoing diarrhea; both were documented as being on enhanced barrier precautions, and staff stated contact isolation orders should have been in place.
A cognitively impaired resident suffered significant injuries in an LTC facility, allegedly at the hands of a roommate. Despite the resident's limited communication abilities, he indicated his roommate as the assailant. The facility's staff discovered the injuries during morning rounds, and the police were notified. The roommate denied the allegations, although bruising was noted on his hands. The facility's policy on abuse prevention was reviewed, revealing a failure to protect the resident from harm.
A resident with a traumatic wound on the left knee was discharged without appropriate follow-up for an infection indicated by an abnormal wound culture. Despite signs of infection, no new physician orders were obtained before discharge. The issue was compounded by a language barrier with the nurse, leading to confusion about necessary follow-up actions.
The facility failed to manage medications appropriately for two residents. One resident did not receive prescribed Xanax due to a lack of communication with the NP or Physician, despite a family request for discontinuation. Another resident missed several doses of prescribed antibiotics, with notes indicating the medications were on order. The Interim Administrator could not provide further information on the missed administrations.
The facility's main kitchen was found to have several sanitation deficiencies, including improperly stored food, dusty equipment, and a malfunctioning dishwasher. A dietary employee failed to follow proper sanitary procedures, such as changing gloves and wearing a beard guard while preparing food. These issues had the potential to affect 137 residents.
The facility's main kitchen area was found to have sanitation deficiencies, including dust and debris accumulation on floors, piping, and fan blades, as well as loose baseboards. These issues were observed during a Kitchen Sanitation Tour, and the Dietary Food Manager acknowledged the need for cleaning and repair.
A resident with severe cognitive impairment and a history of cerebral infarction and chronic respiratory failure did not receive adequate oral care, despite being dependent on staff for personal hygiene. Observations showed the resident's mouth was dry and crusty, with discolored teeth and buildup, indicating a failure to follow the care plan and physician's orders for oral care every shift. Staff interviews revealed oral care was limited to using a foam swab with mouthwash, without brushing the resident's teeth.
A resident with impaired vision did not receive necessary services due to the facility's failure to reschedule a cataract evaluation. The resident initially canceled an appointment due to weather and required a stretcher for transportation, complicating access to care. Despite recommendations for further evaluation, the facility did not document efforts to arrange the needed services.
A resident with hemiplegia and hemiparesis was improperly transferred by CNAs without using the required Hoyer lift, as indicated on the Resident Care Sheet. The resident was unable to sit upright and was falling backward during the attempted transfer. Despite facility policy emphasizing the use of mechanical lifts, staff were unaware of the requirement, leading to non-compliance with safe handling protocols.
A facility failed to administer gastrostomy tube feedings as ordered for a resident with severe cognitive impairment and chronic health conditions. The resident's feeding pump was set to infuse at 70 ml/hour, contrary to the physician's order of 75 ml/hour. The care plan required specific feeding protocols, which were not followed, and the DON had no additional information on the issue.
A resident with acute respiratory failure and chronic bronchitis was observed receiving oxygen at a flow rate of 4.5 lpm, contrary to the physician's order of 3 lpm if oxygen saturation was 90% or below. The care plan required adherence to physician's orders for oxygen therapy, but this was not followed, resulting in a deficiency.
A resident with a history of spinal fusion surgery did not receive prescribed Tramadol for pain management due to the facility's failure to follow up on a pain specialist's order. The resident's daughter provided the medication to the facility, but it was not administered as there was no documented order. The facility's NP assessed the resident and determined Tylenol was sufficient, without further follow-up with the specialist.
A facility failed to update a physician's orders after a medication regimen review for a resident with end-stage renal disease. The review recommended changing hydroxyzine administration from nightly to as needed, but the orders were not updated accordingly. A Nurse Consultant confirmed the oversight.
The facility failed to manage medications for two residents, one attending dialysis and another with diabetes. A resident's Pepcid was not administered during dialysis times, and another resident's insulin was not documented despite recorded blood sugar levels. The facility's policies did not address these scheduling and documentation issues.
Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying an 8% error rate during a medication pass observation. During a morning medication pass, RN 1 prepared insulin for Resident G after obtaining a glucometer reading of 285. Based on the resident’s physician orders, this blood sugar level required administration of 6 units of Lispro (Novolog) insulin per sliding scale, and the resident also had a separate order for 46 units of Glargine (Lantus) insulin to be given daily. RN 1 removed two insulin pens from the cart and dialed 46 units on the Lantus pen and 6 units on the Novolog pen. Before administering the insulin, RN 1 entered the resident’s room and was stopped. She then stated she was unsure about priming the insulin pens and did not know the correct way to prime them. The facility’s insulin pen administration policy required priming insulin pens with 2 units of insulin prior to administering the ordered dose. At the time of the survey, the DON reported that RN 1 was new to the facility and had been oriented to the medication pass policies and procedures. Resident G’s record documented a diagnosis of diabetes mellitus and contained the physician’s orders for both the sliding scale Lispro (Novolog) and daily Glargine (Lantus) insulin that were involved in the observed error.
Soiled Bed Linens Found on Multiple Made Beds in AACU
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, safe, and homelike environment by allowing multiple residents to have made beds with visibly soiled linens on the Advanced Alzheimer’s Care Unit (AACU). During observations conducted with the AACU Supervisor, four of seven resident beds were found with dirty linens despite appearing to be made. One resident’s bed had a moderate amount of a brown substance on the top sheet hanging over the side of the bed, which the AACU Supervisor acknowledged. Another resident’s bed, when the top sheet and cover were removed, revealed brown stains on the bottom sheet. A third resident’s bed was made with a bottom sheet, top sheet, and bed cover, but when the top layers were removed, food crumbs were observed on the bottom sheet and a brown substance was present on the pillowcase. A fourth resident’s bed, made with a bottom sheet and bath blanket, was found to have brown stains on the bottom sheet once the blanket was removed. The AACU Supervisor stated that these four beds had soiled linens that had been made without the linens being changed by the night shift. The Administrator later reported that both night and day shift staff denied making the beds and suggested that residents may have made them, and also indicated there was no facility policy for changing linens. The residents involved all had significant cognitive impairments and varying levels of dependence on staff for activities of daily living (ADLs). One resident with Alzheimer’s disease had a severely impaired cognitive status, required staff assistance for bed mobility, bathing, and transfers, and was occasionally incontinent; her care plan noted she would sometimes make her own bed but required one to two staff for ADLs and short, simple instructions. Another resident with vascular dementia had a severely impaired cognitive status, was dependent on staff for toileting, showers, dressing, bed mobility, transfers, and ambulation, and was frequently incontinent; there was no care plan indicating she made her own bed. A third resident with dementia and bipolar disorder required moderate to maximum assistance for ADLs, was frequently incontinent, and had impaired cognition with need for cueing and supervision, with no care plan indicating she made her own bed. The fourth resident, with Alzheimer’s disease and severely impaired cognition, required staff assistance for ADLs, was frequently incontinent, and also had no care plan indicating he made his own bed.
Dishwasher Chemical Sanitizer Testing Not Maintained
Penalty
Summary
The facility failed to ensure a sanitary kitchen was maintained related to testing of the chemical dishwasher. During the initial kitchen tour, the Dietary Service Manager stated the dishwasher was a chemical system and that the dishwashing solution was tested every shift. He first used a test strip from a bottle on top of the dishwasher and placed it on a tray through the dishwasher; when the cycle was complete, the strip read 50 ppm, and he stated it should be 150 ppm. He then said the wrong strips had been used and retrieved the correct strips, but when he repeated the process, the strip washed away. When he tried again, the strip again washed away. He then dipped a strip into the dishwashing solution, and it did not register any ppm reading. Dietary Aides 1, 2, and 3 were present washing dishes and stated they had not tested the solution that day. The August 2025 Dish Machine Temperature Log showed that on 8/1, 8/2, 8/3, and 8/4 the wash temperature was 160 degrees Fahrenheit and the rinse temperature was 150 degrees, but the ppm column was blank. The facility policy for chemical sanitation stated the sanitizing solution shall be 50 ppm hypochlorite on the dish surface in the final rinse and that chemical solutions shall be maintained at the correct concentration based on periodic testing at least once per shift, with results recorded.
Environment Not Kept Clean and in Good Repair
Penalty
Summary
The facility failed to ensure the residents’ environment was clean and in good repair in 3 of 3 units, including Reflections, C-wing, and D-wing. During an environmental tour with the Regional Maintenance Director and the Housekeeping Manager, surveyors observed several discolored and stained ceiling tiles and dirty ceiling vents throughout C-wing and Reflections. In C-wing, the window curtain fasteners were broken in a room occupied by two residents, the window sills in the lounge/common area had peeling wallpaper underneath them, and there were two large gouges in the wall across from the nurses’ station. In D-wing, the flooring in a room occupied by two residents was marred and had black scuff marks throughout the room. At the time of the observation, the Regional Maintenance Director and the Housekeeping Manager indicated the conditions were in need of cleaning and/or repair.
Failure to Document Interventions Before PRN Anti-Anxiety Medications
Penalty
Summary
The facility failed to ensure interventions were attempted before administering PRN anti-anxiety medications for one resident reviewed for mood and behavior. The resident had diagnoses including Alzheimer's disease, psychotic disorder with delusions, and anxiety disorder, and the Significant Change MDS dated 7/16/25 indicated severe cognitive impairment. The care plan, updated on 11/8/24, identified the resident's use of psychotropic medications related to psychotic disorder, depression, and anxiety. Physician's orders dated 7/10/25 and 7/7/25 authorized lorazepam 1 mg every 8 hours PRN for anxiety and hydroxyzine pamoate 25 mg every 8 hours PRN for anxiety. The MAR for 7/2025 showed lorazepam was given on 7/11/25 at 10:15 a.m. and on 7/16/25 at 2:00 a.m., 10:07 a.m., and 6:12 p.m., and hydroxyzine was given on 7/7/25 at 2:27 p.m. and 7/11/25 at 6:22 a.m., without any prior interventions documented. During interview, the DON stated she was unable to provide further documentation, and the facility policy required documentation of the resident's reason and assessment findings before administering a PRN medication.
Missing Care Plan for Anti-Anxiety Medication Use
Penalty
Summary
The facility failed to ensure a care plan was developed and in place for a resident receiving anti-anxiety medication. Resident 11 had diagnoses including fracture of the right femur, rheumatoid arthritis, and generalized anxiety disorder. The admission MDS dated 6/27/25 indicated the resident was cognitively intact and dependent for toileting, bed mobility, and transfer assistance. The resident received anti-anxiety medications, including a Nurse Practitioner order dated 7/30/25 for chlordiazepoxide 5 mg every 8 hours as needed for anxiety for 14 days, and the current Physician Order Summary listed clonazepam 5 mg every 12 hours for anxiety. Record review found no care plan related to anti-anxiety medication use. Although the DON later provided care plans related to a mood problem, psychotropic medication use, and discharge planning, those care plans did not identify the resident's anti-anxiety medication use or include interventions related to anxiety. During interview, the MDS Nurse stated that if a resident was taking an anti-anxiety medication, there should be an Anti-anxiety Medication Care Plan.
Failure to Provide Needed Fingernail Care
Penalty
Summary
The facility failed to ensure a dependent resident received the ADL assistance required related to dirty, uncut fingernails. Resident 144 had diagnoses including diabetes mellitus, congestive heart failure, and osteoarthritis. The resident’s MDS assessment dated 6/15/25 indicated moderate cognitive impairment, substantial assistance needed for bed mobility, and dependence for transfers and toileting. The current ADL care plan identified a self-care deficit and need for 1-2 person assistance with bathing and 1 person assistance with personal hygiene and oral care as needed. During observation on 8/4/25, the resident stated he was not getting his scheduled showers and that his fingernails had not been cleaned; dark debris was observed under his fingernails. On 8/8/25, the resident again stated he had received a bath but his fingernails still had not been cleaned or cut, and his fingernails were slightly long with dark debris under them. During interview, the MDS Nurse stated that she would take care of his fingernails.
Catheter Bag and Tubing Left on Floor
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter collection bag and tubing were kept off the floor for a resident with a history of infection. Resident 91 had diagnoses including end stage renal disease, neurogenic bladder, and hypertension, and was dependent on staff for bed mobility and transfers. The resident had an indwelling urinary catheter, and the care plan directed staff to keep the drainage bag below the level of the bladder at all times and off the floor. On two separate observations, the resident was lying in bed with the catheter bag resting on the floor, and on the second observation both the catheter bag and tubing were on the floor next to the bed. Record review also showed a physician note documenting MRSA infection at the suprapubic catheter site and treatment with Bactrim. An RN acknowledged that the catheter bag and tubing should not have been on the floor.
Oxygen Order Lacked Clear Direction
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who had diagnoses including atrial fibrillation, hypertension, COPD, and respiratory failure. The resident was cognitively intact, had impairment in both upper and lower extremities, and was dependent on staff for upper body dressing, personal hygiene, bed mobility, and transfers. He received oxygen therapy and was observed with a portable oxygen tank attached to his wheelchair, with oxygen running at 4 liters via nasal cannula during one observation and 2 liters during another observation. Record review showed a care plan for emphysema, COPD, and respiratory failure with an intervention for oxygen via nasal prongs as ordered. A physician’s order dated 5/8/25 stated the resident may receive oxygen at 3 liters via nasal cannula if oxygen saturations were below 90% every shift. The August 2025 MAR documented the oxygen order for 3 liters as administered every shift, and oxygen saturations were recorded above 90% each shift. However, the record lacked documentation stating how much oxygen the resident was to receive when oxygen saturations were above 90%. RN 1 stated the resident was supposed to be on 3 liters of oxygen and that the continuous oxygen order would have to be clarified, and the VPRC stated the order would have to be clarified with the physician.
Narcotic and PRN Medication Documentation Errors
Penalty
Summary
The facility failed to ensure a narcotic pain medication was obtained and administered as ordered, and failed to accurately record PRN medications as dispensed on the MAR for one closed record reviewed. The resident involved had diagnoses including malignant neoplasm of the left bronchus and Hodgkin's lymphoma and was receiving hospice services. A family member stated the resident had stage 4 lung cancer, had pain issues, and had difficulty asking for PRN medications. The resident was admitted for a respite stay and later discharged home. A physician ordered a fentanyl patch 50 mcg every 72 hours for pain, but the August MAR showed it was due on 8/2 and again on 8/5 and was not given. Medication notes stated the patch was on order and later not available, but there were no progress notes showing the family or pharmacy had been contacted about the missing medication. The resident also had orders for morphine sulfate 20 mg/1 ml, 0.25 ml every 2 hours PRN for pain, and lorazepam 2 mg/1 ml, 0.25 ml every 4 hours PRN. The July MAR showed no PRN morphine sulfate or lorazepam given, while the August MAR documented once-daily doses of both medications on multiple days. The narcotic reconciliation sheet showed different administration entries than the MAR, including morphine sulfate and lorazepam doses that were not documented on the MAR, and the DON stated nurses were documenting medication use on the reconciliation sheets instead of the MAR.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% for 1 of 8 residents observed during medication administration. During observation of medication pass for Resident 41, RN 1 prepared aspirin 81 mg enteric coated tablet, Certavite/multivitamin tablet, clopidogrel 75 mg tablet, escitalopram 5 mg tablet, levetiracetam 500 mg tablet, lisinopril 20 mg tablet, and metoprolol succinate extended-release 25 mg tablet, placed them into medication bags, crushed the medications, and administered the crushed medications mixed with applesauce. Review of the resident’s August 2025 Physician’s Order Summary showed aspirin 81 mg chewable tablet once daily and metoprolol succinate extended release 25 mg once daily. During interview, RN 1 stated the aspirin and metoprolol should not have been crushed because they were enteric coated and extended-release medications, and said the pharmacy did not account for the form needed for safe administration. The observation resulted in 2 medication errors during 27 opportunities for error, for a medication error rate of 7.41%.
Infection Control and Isolation Orders Not Properly Implemented
Penalty
Summary
The facility failed to ensure infection control guidelines were in place and implemented during insulin administration for one resident observed receiving insulin. During a medication pass observation, an RN prepared to give insulin lispro to the resident, performed hand hygiene, donned clean gloves, wiped the insulin vial with an alcohol wipe, and then used the same alcohol wipe to clean the resident’s abdominal injection site before administering 24 units subcutaneously. When interviewed, the RN stated she used the same alcohol swab because she had only brought one with her and used one side for the vial and the other side for the resident’s abdomen. A facility policy was requested, but an applicable policy was not available. The facility also failed to have physician’s orders for contact isolation for two residents who were being managed with transmission-based precautions. One resident had a contact isolation sign posted at the room entrance and was documented as being on enhanced barrier precautions, with records showing treatment with vancomycin for an MRSA-related infection after left shoulder surgery; however, there were no physician’s orders or care plan for contact isolation. Another resident had a history of C. difficile infection, was still reported to have diarrhea, and was documented as being on enhanced barrier precautions, but there were no orders for contact isolation. The Infection Preventionist and Assistant DON stated both residents should have had contact isolation orders.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident, Resident B, from physical abuse, resulting in significant injuries. Resident B, who suffers from paranoid schizophrenia, hemiplegia following a stroke, and vascular dementia, was found with multiple injuries, including swelling and discoloration of the eyes, a swollen wrist, and lacerations on the right toe and ankle. The incident was reported to have occurred in the morning, and upon questioning, Resident B pointed to his roommate, Resident C, as the perpetrator. Resident C, who is cognitively intact but has mobility impairments, denied the allegations, although bruising was noted on his hands. The incident was discovered by a CNA during morning rounds, who observed blood on Resident B's bed and injuries on his body. Despite Resident B's limited verbal communication abilities, he indicated Resident C as the assailant. The facility's staff, including CNAs and nurses, were interviewed, and none reported witnessing the incident or any prior behavioral issues between the two residents. The police were notified, and an investigation was conducted, but no conclusive evidence was found to confirm the assault, although Resident C was found with a pocketknife and scissors in his possession. The facility's policy on abuse, neglect, and exploitation was reviewed, which mandates the protection of residents and the investigation of alleged abuse. However, the report indicates a failure to prevent the incident and protect Resident B from harm. The facility's response included notifying the police, conducting interviews, and separating the residents, but the deficiency highlights a lapse in ensuring the safety and well-being of residents, particularly those who are vulnerable due to cognitive impairments.
Failure in Discharge Planning for Resident with Wound Infection
Penalty
Summary
The facility failed to implement a complete discharge planning process for a resident with a traumatic wound on the left medial knee. The resident, who was cognitively intact and required substantial assistance for hygiene and transfers, had an abnormal wound culture indicating an infection. Despite the presence of signs of infection such as redness, warmth, and swelling, there was no follow-up or new orders from the physician prior to the resident's discharge. The resident was discharged home with family, and the abnormal wound culture results were not addressed until after the discharge. The deficiency was identified when the facility did not ensure ongoing physician follow-up for the abnormal wound culture results. The wound culture, which showed the presence of enterobacter cloacae and staphylococcus aureus, was not acted upon before the resident's discharge. The physician was informed of the results, but no new orders were given at the time, and the resident was discharged without appropriate treatment for the infection. The issue was further complicated by a language barrier with the nurse who documented the notes, leading to confusion about the orders and follow-up required.
Medication Management Deficiencies for Two Residents
Penalty
Summary
The facility failed to manage medications appropriately for two residents, leading to deficiencies in medication administration. Resident B, who had multiple fractures and insomnia, was prescribed Xanax but did not receive it from 7/3/24 to 7/9/24. The resident's son requested the discontinuation of Xanax, but there was no documentation of communication with the Nurse Practitioner or Physician to discontinue the medication until 7/15/24. The Interim Administrator confirmed that the medication was not available and acknowledged the family's request for discontinuation, but no action was taken to address the medication order until later. Resident G, diagnosed with a wound infection, high blood pressure, and type 2 diabetes, was prescribed a regimen of antibiotics, including Cefazolin, Ceftriaxone, and Vancomycin. However, these medications were not administered as ordered on several occasions in July 2024, with Nurses' Notes indicating that the medications were on order. The Interim Administrator could not provide further information regarding the missed antibiotic administrations. This deficiency was related to a specific complaint, IN00439994.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, which had the potential to affect 137 residents. During a kitchen sanitation tour, several issues were observed, including a bag of noodles in the dry storage room that was not properly fastened, resulting in loose noodles on shelves and food boxes. Additionally, there was an accumulation of crumbs and dust on the upper shelf of the oven, and dust and dried food spillage on the front of the convection oven. A large fan in the dish room was covered in dust and was blowing towards clean dishes. Furthermore, the high-temperature dishwasher's final rinse temperature gauge was not functioning correctly, consistently registering 140 degrees Fahrenheit, which was below the required temperature for effective sanitation. In another observation, a dietary employee was seen handling food without following proper sanitary procedures. The employee donned clean gloves but did not change them after touching various items, including a bag of lettuce, a knife, and a boiled egg. Additionally, the employee was not wearing a beard guard while preparing the salad. These actions were acknowledged by the Dietary Food Manager, who indicated that the areas observed needed cleaning and that the employee should have adhered to proper sanitary protocols.
Sanitation Deficiencies in Kitchen Area
Penalty
Summary
The facility failed to maintain a sanitary environment in the main kitchen area, as observed during a Kitchen Sanitation Tour. The deficiencies included an accumulation of dust and debris on the floor and piping behind the convection oven, as well as dried food spillage on white pipes. Additionally, a ceiling vent between the steam table and the kitchen exit door was covered in dust. In the dish room, a fan mounted on the wall had dust on its blades and cover, although it was not in use at the time. Furthermore, the baseboard beneath the eye wash sink in the dish room was loose and detached in some sections. During an interview, the Dietary Food Manager acknowledged the need for cleaning and repair in these areas.
Inadequate Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for a resident who was dependent on staff for oral hygiene. Observations on multiple occasions revealed that the resident's mouth was dry and crusty, and his teeth were discolored with buildup. Despite a care plan indicating the need for oral care assistance and a physician's order for oral care every shift, the resident did not receive proper oral hygiene care. The Medication Administration Record indicated that oral care was signed off as completed every shift, yet the resident's condition suggested otherwise. The resident, who was severely cognitively impaired and dependent on staff for personal hygiene, had a history of cerebral infarction and chronic respiratory failure. Interviews with staff revealed that oral care was limited to wiping the resident's mouth with a foam swab dipped in mouthwash, without using a toothbrush. The Nurse Consultant confirmed the resident's inability to follow commands for oral care but did not provide further information. This lack of comprehensive oral care led to the deficiency noted in the report.
Failure to Provide Necessary Vision Services for a Resident
Penalty
Summary
The facility failed to ensure that a resident with impaired vision received necessary services. The resident, who was cognitively intact and had a history of chronic obstructive pulmonary disease and hyperlipidemia, expressed the need to have his cataracts checked. An appointment for a cataract evaluation was initially scheduled but canceled by the resident due to cold weather, with the intention to reschedule when the weather improved. Despite a subsequent optometry note recommending a cataract evaluation and possible treatment, there was no documentation indicating that the facility made efforts to reschedule the appointment or arrange for the recommended eye care services. The resident's care plan meetings noted the last optometry visit, but no further actions were documented. Social Services staff acknowledged the challenge of finding a traveling eye doctor due to the resident's transportation needs, as he required a stretcher and assistance that ambulance staff would not provide. However, there was no documentation of follow-up actions taken to address the optometry recommendation, and the staff member admitted to needing better documentation practices.
Improper Transfer of Resident Without Required Mechanical Lift
Penalty
Summary
The facility failed to ensure a dependent resident was transferred using a Hoyer lift as indicated on the Resident Care Sheet. On the morning of June 11, a CNA attempted to transfer a resident from her bed to a wheelchair without using the required mechanical lift. The resident, who had hemiplegia and hemiparesis, was unable to sit upright and was falling backward during the attempted transfer. The CNA instructed the resident to hold onto her neck, but the resident was unable to comply due to her physical limitations. Another CNA intervened, indicating that the resident required a sit-to-stand lift, highlighting the improper transfer method being used. Further review of the resident's records confirmed that she was dependent on a Hoyer mechanical lift for transfers. Despite this, another CNA admitted to transferring the resident by standing and pivoting her to the wheelchair, unaware of the requirement for a mechanical lift. The facility's policy on Safe Resident Handling/Transfers emphasizes the use of mechanical lifts for safe handling, which was not adhered to in this instance. The deficiency was identified through observation, record review, and interviews with staff, revealing a lack of compliance with established transfer protocols.
Improper Gastrostomy Tube Feeding Administration
Penalty
Summary
The facility failed to ensure proper gastrostomy tube care for a resident, identified as Resident 54, who was dependent on tube feedings. Observations on two separate occasions revealed that the resident's tube feeding pump was set to infuse Jevity 1.5 cal at 70 ml/hour. However, the physician's order specified that the feeding should be administered at 75 ml/hour for 22 hours a day. The resident, who was severely cognitively impaired and dependent on staff for various hygiene needs, had diagnoses including cerebral infarction and chronic respiratory failure. The care plan required the head of the bed to be elevated during and after feedings, and for feedings to be administered as ordered, which was not adhered to in this instance. The Director of Nursing was unable to provide further information regarding the discrepancy.
Improper Oxygen Administration for a Resident
Penalty
Summary
The facility failed to provide proper care and treatment related to oxygen administration for a resident. Resident 13, who was diagnosed with acute respiratory failure, chronic bronchitis, and adult failure to thrive, was observed on two occasions with an oxygen concentrator set to a flow rate of 4.5 liters per minute (lpm) via nasal cannula. However, the physician's order specified that oxygen should be administered at 3 lpm if oxygen saturations were 90% or below, as needed for shortness of breath. The resident's care plan also indicated that oxygen therapy should be administered as needed per physician's orders. Despite these directives, the oxygen flow rate was not adjusted according to the physician's order, leading to a deficiency in the resident's care.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure a follow-up for a pain specialist's medication order for a resident with a history of spinal fusion surgery and other conditions, who was experiencing pain during activities of daily living and therapy. The resident's daughter had taken her to a pain specialist who prescribed Tramadol, an opioid pain medication, to be used as needed. The daughter filled the prescription at a pharmacy and brought it to the facility, but the medication was never administered to the resident. The facility staff claimed there was no order for the medication and that pain assessments indicated the resident was not in pain. The resident's medical records showed a diagnosis of wedge compression fracture, dementia with psychotic disturbance, and arthrodesis. The care plan included administering pain medication as ordered, but the Physician's Order Summary only listed Tylenol, with no mention of Tramadol. Progress notes indicated that the resident's daughter had requested the Tramadol be administered, but the facility's Nurse Practitioner denied the request, believing Tylenol was sufficient. There was no documentation of follow-up with the pain specialist or communication with the resident's daughter regarding the medication. Interviews with facility staff revealed that the resident's daughter had provided the Tramadol to the nurse without an accompanying order or script. The Director of Nursing and the D Wing Unit Manager both acknowledged the lack of follow-up with the pain specialist and the absence of a valid prescription. The facility's policy required verification of orders and prescriptions for controlled substances, but this process was not completed, resulting in the resident not receiving the prescribed pain medication.
Failure to Update Physician's Orders After Medication Review
Penalty
Summary
The facility failed to update a physician's orders following a medication regimen review for a resident with end-stage renal disease and dependence on renal dialysis. The resident's record was reviewed, revealing that a Pharmacy Medication Regimen Review recommended reducing polypharmacy. The review suggested changing the administration of hydroxyzine from a regular nightly dose to as needed. However, the June 2024 Physician's Order Summary still indicated hydroxyzine to be administered nightly, contrary to the recommendation. During an interview, a Nurse Consultant acknowledged that the orders should have been updated.
Medication Management Deficiencies for Dialysis and Insulin Administration
Penalty
Summary
The facility failed to manage and monitor the medication regimen of two residents, leading to deficiencies in their care. Resident 28, who attended dialysis three times a week, had a physician's order for Pepcid to be administered in the afternoon on dialysis days. However, the medication was not given on multiple occasions because the resident was not present at the facility during the scheduled administration times. The facility's administrator acknowledged that the medication was scheduled during dialysis times and later indicated that the medication had been discontinued. The facility's medication administration policy did not address medication scheduling, contributing to the oversight. For Resident 74, who had diagnoses including type 2 diabetes mellitus, there were significant lapses in documenting blood sugar levels and insulin administration. The resident's care plan required glucose monitoring and insulin administration per a sliding scale. However, the Medication Administration Record (MAR) showed blanks for blood sugar results and insulin administration on several dates and times. Although blood sugar levels were recorded in a daily log, there was no corresponding documentation of insulin administration. The Director of Nursing explained that when a Qualified Medication Aide (QMA) was on duty, blood sugars were logged on paper, and nurses administered insulin without documenting it in the MAR. This lack of documentation was identified during monthly audits, but the issue persisted.
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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.
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Nursing homes near Merrillville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Mill Health Campus | 0.4 mi | ★★★★★ | 21 | 0 |
| Lincolnshire Health & Rehabilitation Center | 0.6 mi | ★★★★★ | 38 | 0 |
| Colonial Nursing Home | 3 mi | ★★★★★ | 0 | 0 |
| Saint Anthony | 4.5 mi | ★★★★★ | 3 | 0 |
| Ignite Medical Resort Crown Point Llc | 4.9 mi | ★★★★★ | 37 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.