Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 - Petersburg Care Center during CMS and state inspections, most recent first.
Uncertified Dietary Manager: The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services because the Dietary Manager was not certified. The Administrator stated the DM had failed the test, was registered to retake it, and another dietary staff member’s certification had expired.
Failure to notify the MD and family of changes in condition: one resident had significant weight loss and right wrist skin tears, but the record lacked documentation of physician or family notification and no orders were documented for the skin injury. Another resident had ongoing significant weight loss during weekly nutrition at-risk review, but progress notes lacked documentation that the MD was notified. Staff interviews confirmed that new skin conditions and major weight changes should be reported, but the required notifications were not documented.
Failure to provide needed denture and oral hygiene assistance: A resident with severe cognitive impairment, Alzheimer's disease, Parkinson's disease, and intellectual disabilities was dependent for oral care and wore upper and lower dentures. Surveyors observed crusty debris on the resident's mouth and lips, and record review showed repeated dental findings of heavy plaque, calculus, and staining on the dentures. Dental notes instructed nightly denture removal, soaking, and brushing, but a CNA reported the dentures were not always removed at night and were sometimes still slimy and covered in debris.
A resident with COPD, DM2, and recent hip surgery had significant weight loss after returning from the hospital. The RD noted poor/variable intake and recommended house shakes or fortified foods, but the shake order was delayed and the resident continued to lose weight. The record lacked documentation of MD and family notification, resident/staff education about nutrition risks, and any alternative interventions beyond the shake.
Improper Hand Hygiene and Glove Use During Wound Care: A wound care NP failed to perform hand hygiene before donning gloves, touched the resident, bed rail, curtain, and her phone while wearing the same gloves, and handled wound beds with contaminated gloves during a dressing change. The NP also washed her hands for only a few seconds, changed gloves without hand hygiene, and rolled the resident onto a visibly soiled incontinence pad while the DON and an LPN observed without intervening.
The facility failed to ensure a clean and homelike environment, with issues such as peeling baseboards, exposed pipes, and an air conditioning unit falling off the wall. Water temperatures in several rooms exceeded the recommended maximum, with some reaching 127.5 degrees Fahrenheit. The maintenance assistant had not calibrated the thermometer used for checking water temperatures, and the facility's policies on maintaining a safe environment were not followed.
The facility failed to ensure call light accessibility for two residents. One resident's call light was repeatedly found on the floor, out of reach, despite her care plan requirements. Another resident, with a history of behavioral disturbances, had no call light in her room due to her tendency to throw items. Instead, a Wander Guard was used, but its placement and function were not consistently checked. The facility lacked documentation of staff checks and had no policy for the Wander Guard, although it was stated that provider's orders should be followed.
The facility failed to ensure accurate MDS Assessments for several residents, leading to discrepancies in recorded diagnoses and medication administration. Errors included incorrect documentation of anticoagulant use, unrecorded diagnoses of anxiety, depression, PTSD, and schizoaffective disorder, and a misreported diagnosis of atrial fibrillation. These inaccuracies were identified through interviews and record reviews, with the Regional Nurse acknowledging the discrepancies and the lack of a specific policy for MDS Assessments.
A facility failed to provide necessary care and complete assessments for a resident requiring dialysis. The resident's medical record lacked post-dialysis documentation, and the facility did not have a current dialysis contract. Observations showed incomplete or missing post-dialysis assessments, and staff interviews confirmed the expectation to perform and document these assessments. The facility's Hemodialysis Policy required ongoing assessment and monitoring, which was not adhered to, as evidenced by the lack of documentation and absence of a current dialysis contract.
Uncertified Dietary Manager
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 kitchen observed because the Dietary Manager was not certified. During an interview on 11/17/25, the Dietary Manager was asked to provide her certification certificate. On 11/21/25, the Administrator stated that the Dietary Manager had failed the test and was registered to take it again, but the new test date was unknown. The Administrator also stated that another dietary staff member had been certified until that certification expired in September 2025. A current, undated Dietary Services Policy provided by the Administrator stated that the facility employs sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services.
Failure to Notify Physician and Family of Significant Weight Loss and Skin Tears
Penalty
Summary
The facility failed to ensure that changes in condition were promptly reported to the resident, the resident’s physician, and a family member for two residents. For one resident, the record showed significant weight loss over several months, including a drop from 101.2 lbs to 94 lbs, and the clinical record lacked documentation that the physician or family were notified of the continued weight loss. The resident also had diagnoses including COPD, diabetes mellitus type II, and anxiety, and was observed with a bandage on the right wrist that was not dated. The same resident had a progress note documenting dried blood and two small skin tears on the right wrist, and a weekly skin assessment noted a small skin tear to the top of the right forearm covered with border gauze. The record lacked documentation that the physician was notified or that orders were received for the skin tears. During interviews, staff indicated that new skin conditions should be reported to the MD and family, and that bandages should be dated and initialed when changed, but no documentation showed that this occurred for the resident’s right wrist skin tears. For the second resident, the record showed ongoing significant weight loss while on weekly nutrition at-risk review, with weights declining from 223.6 lbs to 189.2 lbs over several months. Interdisciplinary nutrition at-risk meetings were documented, but the progress notes lacked documentation that the physician was notified of the significant weight changes. The DON stated the resident had been on weekly nutrition at-risk meetings related to unexplained weight loss and that if the physician had been notified, it was not documented. The facility policy provided that the facility promptly informs the resident, consults the physician, and notifies the resident’s representative when there is a change requiring notification.
Failure to Provide Needed Denture and Oral Hygiene Assistance
Penalty
Summary
The facility failed to ensure a dependent resident received the necessary assistance with oral hygiene and denture care to maintain good grooming and personal hygiene. The resident had diagnoses including Alzheimer's disease, Parkinson's disease, and intellectual disabilities, and the most recent MDS indicated severe cognitive impairment and substantial to maximum assistance needed with oral hygiene. The care plan stated the resident wore upper and lower dentures and included mouth care as part of ADL personal hygiene, but the resident was observed with crusty debris on the mouth and lips, and dentures were not observed during the observation. Record review showed repeated dental findings of poor denture hygiene. A dental visit form documented extremely heavy plaque, calculus, and staining on the dentures, with instructions to remove dentures nightly, soak them in water or denture cleaning tablet, and brush them in the morning. Later dental visits documented heavy plaque, that the resident wore the dentures all the time and never removed them, and poor oral health with heavy plaque and debris; the dental provider noted the resident would benefit from staff assistance to remove, clean, and soak the dentures every night. A CNA stated that although the dentures were sometimes found soaking in the morning, at other times they were still in the resident's mouth, and when removed they were sometimes slimy and covered in debris.
Failure to Address Ongoing Weight Loss and Nutrition Needs
Penalty
Summary
The facility failed to ensure adequate nutrition support for a resident who was underweight and continued to lose weight after returning from the hospital following left hip surgical repair. The resident had diagnoses including COPD, type II diabetes mellitus, and anxiety, and was cognitively intact and able to feed herself. Her documented weights showed a decline from 101.2 lbs to 94 lbs over about five weeks, including a 6.72% loss in one day and a 7.11% loss by 11/18/25. The most recent MDS showed no significant weight loss at that time, but later weight monitoring identified ongoing loss. A Nutrition Assessment Review on 10/16/25 documented that the resident had lost 6 lbs in the past couple of weeks/month, described the loss as significant, and recommended house shakes or fortified food because of weight loss, poor/varied oral intake, and recent surgery. The record showed the house shake order was not entered until 15 days later. Subsequent nutrition notes documented variable meal intake and that the resident liked and tried chocolate house shakes, but the resident continued to lose weight. The record lacked documentation of notifications to the physician and family about the weight loss, education to the resident about weight loss and nutrition risks, and any alternative interventions after the resident continued to lose weight on the current intervention. The 30-day physician follow-up note lacked documentation of the resident’s fluctuating weight, weight loss, or education provided to the resident or staff about nutrition. During interviews, CNA staff stated they were to weigh residents and notify nurses of major discrepancies, nurses were to notify the MD and DON and document it, and the DON expected prompt notification to the MD and family with documentation in the clinical record. The DON also stated the dietitian had not recommended any alternative interventions besides the shake and she was not aware of other interventions tried for the resident’s weight loss.
Improper Hand Hygiene and Glove Use During Wound Care
Penalty
Summary
The facility failed to ensure a sanitary environment to help prevent the development and transmission of infections during wound care for Resident 46. During a dressing change on the resident’s leg, a wound care NP entered the room with the DON and an LPN and put on a gown and gloves without first washing or sanitizing her hands. While assisting with turning the resident, the NP touched the resident’s gown and skin, then touched the side rail, the curtain, and her mobile phone screen while still wearing the same gloves. The NP then removed dressings and touched the wound beds with the same gloved hand/finger that had touched other items, and continued touching her phone screen between dressing removals. After removing her gloves, she washed her hands for 3 seconds and later put on clean gloves, assisted in rolling the resident again while touching the sheet and a visibly soiled incontinence pad, and moved the trash can closer to the bed. She removed her gloves again and put on another clean pair without washing or sanitizing her hands before applying dressings. The resident was rolled back onto a visibly soiled incontinence pad with brown, yellow, and red substances. The DON and LPN present during the entire care did not address the NP’s actions.
Environmental and Water Temperature Deficiencies
Penalty
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms and a shower room, as observed during a survey. Specific issues included bathrooms with holes in the walls, exposed pipes, peeling baseboards, uncovered bedpans, and scuffed floors. Additionally, an air conditioning unit was found to be falling off the wall in one room. These conditions were noted in six out of thirteen resident rooms and one of two shower rooms observed. Water temperatures in multiple rooms exceeded the recommended maximum of 120 degrees Fahrenheit, with temperatures recorded as high as 127.5 degrees. Residents reported that the water was hot, though none reported being burned. The maintenance assistant acknowledged that the water lines' location in the attic and external temperatures could contribute to elevated water temperatures. However, there was no recent notification of concerns from staff or residents regarding water temperatures. The maintenance assistant admitted to not calibrating the thermometer used for checking water temperatures, which could affect the accuracy of the readings. The facility's policies on safe water temperatures and maintaining a homelike environment were not adhered to, as evidenced by the conditions observed. The report relates to a specific complaint, indicating ongoing issues with the facility's environment and maintenance practices.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents regarding the accessibility of call lights. Resident 26 was observed multiple times with her call light lying on the floor, out of reach, despite her care plan indicating the need for the call bell to be within reach due to her severe cognitive impairment and mobility issues. The resident's medical records showed diagnoses including non-Alzheimer's dementia and heart failure, necessitating supervision for various activities. A CNA confirmed that the call lights should be within reach of residents, yet this was not adhered to in Resident 26's case. Resident 38, who had a history of dementia with behavioral disturbances, was observed without a call light in her room. The CNA explained that the call light was removed due to the resident's tendency to throw and break items. Instead, a Wander Guard was used, but there was a lapse in checking its placement and function as per the physician's orders. The resident's care plan required the call bell to be within reach, but this was not implemented. The facility lacked documentation of staff checks on the resident, and there was no policy for the Wander Guard, although it was stated that provider's orders and care plan interventions should be followed.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) Assessments for several residents, leading to discrepancies in recorded diagnoses and medication administration. For instance, a resident was incorrectly documented as receiving an anticoagulant when they were only prescribed antiplatelet medications like aspirin and Plavix. Another resident with active diagnoses of anxiety and depression was marked as not having these conditions on their MDS Assessment, despite care plans indicating otherwise. Additionally, a resident with PTSD was not accurately reflected in their MDS Assessment, even though their care plan included a history of trauma and related psychoactive medication. Further inaccuracies were noted with a resident being marked as having atrial fibrillation without any supporting documentation in their clinical record. Another resident with a diagnosis of schizoaffective disorder was not correctly identified in their MDS Assessment, despite it being listed in their care plan. These errors were identified through interviews and record reviews, highlighting a lack of accurate reflection of residents' active diagnoses and medication use in the MDS Assessments. The Regional Nurse acknowledged these discrepancies and noted the absence of a specific policy for MDS Assessments, relying instead on the Resident Assessment Instrument (RAI) manual.
Failure to Provide Complete Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and complete assessments for a resident requiring dialysis services. The resident, who was diagnosed with end-stage renal disease and dependent on renal dialysis, did not have post-dialysis assessment documentation in their medical record. The facility also did not have a current dialysis contract at the time of the survey. The resident's clinical record, including progress notes and the Medication Administration Record (MAR), lacked documentation of post-dialysis assessments, such as vital signs, mental status, and access site evaluations. Observations and interviews revealed that the staff did not consistently complete the post-dialysis assessment sections on the dialysis/observation communication forms. Several forms were either incomplete or missing, and the assessments that were documented often lacked critical information, such as the resident's name, time of completion, and evaluations of pain, mental status, and access site conditions. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the staff was expected to perform these assessments and document them in the resident's clinical record. Additionally, the facility's Hemodialysis Policy outlined the requirement for ongoing assessment and monitoring of residents before and after dialysis treatments, including documentation of vital signs, access site conditions, and any complications. However, the facility did not adhere to these standards, as evidenced by the lack of completed documentation and the absence of a current contract with the dialysis provider. The Administrator acknowledged the absence of a current contract with the dialysis company, further highlighting the facility's failure to ensure proper dialysis care and services.
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What surveyors actually found near you
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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 Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amber Manor Care Center | 1 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Home & Rehabilitative Center | 10.6 mi | ★★★★★ | 1 | 0 |
| Villages At Oak Ridge, The | 12.1 mi | ★★★★★ | 1 | 0 |
| Hillside Manor Nursing Home | 13.4 mi | ★★★★★ | 31 | 1 |
| Prairie Village Nursing And Rehabilitation | 13.5 mi | ★★★★★ | 0 | 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.