Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 - Portage Care Center during CMS and state inspections, most recent first.
Dishwasher Final Rinse Temperature Not Reaching Required Level: A high-temp dish machine in the Main Kitchen was observed in use while the wash, rinse, and final rinse gauges did not move from 150 F, 150 F, and 130 F, respectively. An LPN-equivalent dietary server stated she had not checked the temperatures before use and did not know the required settings, while the DM said the final rinse should have been 180 F and the gauges were not working.
Failure to Follow Medication Parameters and Assess Bruising: The facility did not follow ordered hold parameters for BP meds and insulin for several residents, including giving meds when BP or blood glucose was below the ordered limits and holding a med when it should have been given. Staff also failed to apply ordered TED hose for a resident and did not assess or document bruising/discoloration on residents receiving anticoagulants, despite repeated observations of the affected areas and DON/RN acknowledgment that the findings should have been assessed.
Incomplete and inaccurate clinical documentation was found for a resident on continuous O2 and for three residents with PICC lines or a dialysis graft. A resident ordered continuous O2 was repeatedly observed without oxygen in use even though the TAR showed it as applied, and the DON noted a clarification order would be obtained. Three other residents had orders and care plans restricting BP checks in an arm with an access site, yet the vital signs record documented BP readings on those restricted arms; the Nurse Consultant stated the arm documentation was likely incorrect.
Failure to Maintain Resident Dignity Related to Clothing: A resident with stroke and dementia was repeatedly observed in bed wearing a hospital gown during the day. The resident had severe cognitive impairment, was dependent on staff for dressing, and had no care plan related to wearing a gown while in bed at the time of review. The DON later stated the family wanted the resident to wear a gown in bed for comfort.
Failure to arrange ophthalmology referrals and appointments for a resident with ESRD, HF, stroke, vascular dementia, anxiety, and renal dialysis. Eye exam notes documented a left-eye cataract/posterior capsule opacification and later a right-eye cataract, with recommendations for YAG laser posterior capsulotomy and cataract surgery; the resident wanted to proceed and referrals were given to social service. The SSD said she was unaware of the referrals because the MRS was handling ancillary appointments, and staff reported difficulty finding providers who accepted the resident's insurance.
The facility failed to document bolus tube feedings for a resident with a PEG tube, stroke, dysphagia, dementia, and NPO status, even though nursing notes indicated bolus feedings and flushes were being used due to PEG port issues. The facility also failed to provide ordered PEG site care for another resident with a feeding tube, diabetes, and lupus; the site had a soiled dressing, redness, and drainage, and an LPN admitted he signed off on the MAR without actually completing the ordered cleansing and ointment application.
Failure to Document PICC Line Measurements: A resident with a PICC line and diagnoses including severe protein-calorie malnutrition, colostomy, and intestinal obstruction had a physician order to measure PICC catheter length on admission and with each dressing change. The MAR showed multiple PICC dressing changes, but the record lacked documentation of catheter length measurements. The Nurse Consultant confirmed no PICC length measurements were documented.
A resident with COPD, asthma, and other diagnoses was repeatedly observed in bed wearing oxygen on a room concentrator set at 1.5 L via NC. The care plan directed staff to follow the MD order, but the order specified oxygen at 1 L via NC and to keep O2 saturation about 90%. An RN observed the oxygen at 1.5 L and said she was unaware of the correct setting, while the unit manager stated oxygen should be set per the current MD order.
A resident with type 2 DM and impaired cognition had an order for Insulin Glargine 15 units SQ every morning and at bedtime, with the dose to be held if BG was less than 100. The MAR showed the insulin was given at bedtime, but there was no documentation of BG checks on several dates, and the Nurse Consultant confirmed no BGs were available for review.
The facility failed to ensure proper use of a Hoyer lift for a resident who was dependent on staff for transfers and receiving hospice services; the resident slipped out of the lift pad during a transfer and was found on the floor with right rib-area tenderness. The facility also failed to keep a floor mat beside the bed of another resident with dementia, repeated falls, and a prior femur fracture, despite the care plan directing that a mat be placed by the bed and repeated observations showing none was present.
Lack of Social Services Follow-Up and Documentation: The facility failed to document and follow up on a resident’s repeated 911 calls, an abuse allegation involving a staff assault and missing cell phone, and a referral sent to another nursing home for another resident. The record showed the resident was cognitively intact on MDS but had behavior issues, while Social Services later acknowledged she did not document her interview or follow-up. For the other resident, a referral was faxed and the receiving facility was contacted, but there was no further documentation of the referral outcome.
A resident with a seizure disorder did not receive two scheduled doses of prescribed anti-seizure medication because the medication was unavailable and a new prescription was required by the pharmacy. Documentation showed missed doses, and the medication was not received until after the resident had left the facility.
A resident with a history of stroke and cognitive impairment did not receive timely neurologist appointments due to repeated logistical issues, including transportation failures and scheduling errors. Despite multiple physician's orders, the resident was not seen by a neurologist since admission, and alternative measures were not effectively implemented.
A facility failed to offload a resident's heels while in bed, despite care plans and physician's orders. The resident, with a history of multiple medical conditions and cognitive impairment, developed a pressure ulcer on the left heel. Observations showed the heels were not offloaded, and interviews confirmed the lack of adherence to treatment recommendations.
The facility failed to implement fall prevention measures for two residents at risk for falls. A resident's call light was repeatedly found on the floor, out of reach, despite care plan instructions. Another resident's bed was observed in a high position without a required floor mat, as per physician's orders, due to concerns about the ambulatory roommate tripping. Staff were aware of these issues, but interventions were not consistently applied.
A resident with a Foley catheter was observed multiple times with the catheter bag improperly positioned, either on the floor or above the waist, contrary to care plan instructions. Despite the resident's history of urinary tract infections and the facility's policy, staff failed to consistently maintain the catheter bag below the bladder level and off the floor.
A resident with COPD and high blood pressure was observed receiving oxygen at nearly 3 liters per minute, contrary to the physician's order of 2 liters per minute. Despite this discrepancy, the MAR indicated the oxygen was administered correctly. Interviews with facility staff confirmed the oxygen should have been set at the prescribed rate.
An LPN failed to sanitize reusable instruments between checking the vital signs of two residents during a medication pass, breaching infection control guidelines. The facility's policy requires cleaning and disinfecting multi-resident items after each use, which was not followed in this instance.
Dishwasher Final Rinse Temperature Not Reaching Required Level
Penalty
Summary
The facility failed to ensure a sanitary kitchen when the high temperature dishwasher in the Main Kitchen did not reach the required final rinse temperature. During the initial kitchen tour, the Dietary Manager and Dietary Server 1 were observed using the dishwasher while trays of dishes were being run through it. Three gauges on top of the machine were observed during the wash cycle, and the wash temperature gauge and rinse temperature gauge did not move from 150 degrees F, while the final rinse sanitation gauge did not move from 130 degrees F. The Dietary Manager asked the Dietary Server to run additional cycles, but the gauges still did not move. The Dietary Manager then placed a digital thermometer on a tray and ran it through a cycle, which read 153.6 degrees F. During the observation, Dietary Server 1 stated she had not checked the dishwasher temperatures before using it that day and was unaware she needed to check the gauges or what the appropriate temperatures should have been. The Dietary Manager stated staff should have checked the dishwasher temperature before use, that the final rinse cycle should have been 180 degrees, and that she was unsure why the gauges were not working. The facility policy titled, Dishwasher Temperature, stated that for high temperature dishwashers the final rinse temperature shall be 180 F or above but not to exceed 194 F, and that water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes.
Failure to Follow Medication Parameters and Assess Bruising
Penalty
Summary
The facility failed to provide medications according to physician orders for several residents. For one resident with hypertension and congestive heart failure, Norvasc was administered even when the resident’s systolic blood pressure was below the ordered hold parameter, and Lisinopril was held even though the resident’s blood pressure did not meet the hold criteria. The Director of Nursing stated the Norvasc should have been held and the Lisinopril should have been given. For residents receiving diabetes medications, the facility also failed to follow ordered blood sugar parameters. One resident with type 2 diabetes received Humalog insulin and Nateglinide on multiple occasions when blood glucose values were below the ordered hold threshold of 110. Another resident with type 2 diabetes received Lispro insulin on multiple occasions when blood sugar values were below the ordered hold threshold of 100. The Nurse Consultant stated the medications should have been administered according to the physician’s orders. The facility also failed to carry out ordered care for compression stockings and to assess bruising or discoloration on residents receiving anticoagulants. One resident with stroke, dementia, and heart failure was observed repeatedly without TED hose in place even though the order required daily use, and the Coreg order was also not held when blood pressure parameters were not met. Another resident on Eliquis had a reddish/purple area on the forearm that remained visible over multiple observations, but there was no documentation of when it appeared or that it had been assessed. A third resident with repeated falls and dementia had a large bruise on the left forearm and hand observed over several days, but there was no documentation of assessment or monitoring of the bruising. A fourth resident on Eliquis had a large dark purple discoloration on the left hand, and the record lacked documentation that the area had been assessed or monitored.
Incomplete and Inaccurate Clinical Documentation for Oxygen and Restricted-Arm Blood Pressure Readings
Penalty
Summary
The facility failed to maintain clinical records that were complete and accurately documented related to clarification of oxygen orders and documentation of blood pressure readings on restricted arms for four residents. Resident 112 had diagnoses including CHF and COPD, was cognitively intact, and had a physician order for continuous oxygen at 2 liters per minute via nasal cannula with notification if oxygen saturation was below 90% every shift. However, the resident was observed multiple times without oxygen in use, including while seated in a wheelchair and while being transported, even though the January 2026 TAR showed oxygen signed out as applied for all three shifts on 1/6/26 through 1/8/26. The DON stated a clarification order would be obtained because the resident was not wearing oxygen as ordered. Resident 161 had a PICC line in the left arm and a care plan directing staff not to take blood pressure in the arm with the access site, yet the vital signs record documented blood pressure readings on the left arm on multiple occasions. Resident 92 had a PICC line in the right arm, a physician order stating no blood pressure checks in the right arm, and a care plan directing staff not to take blood pressure in the arm with the access site, but the vital signs record documented repeated blood pressure readings on the right arm. Resident 2 had end stage renal disease, a right arm graft for hemodialysis, a physician order stating no blood pressures were to be taken on the right arm, and a care plan directing staff not to draw blood or take blood pressure in the arm with the graft; however, the vital signs record documented multiple blood pressure readings on the right arm. The Nurse Consultant stated staff must have documented the arm used for blood pressure incorrectly and needed to work with staff on documentation.
Failure to Maintain Resident Dignity Related to Clothing
Penalty
Summary
The facility failed to maintain the dignity of Resident 75 by allowing the resident to remain in a hospital gown while in bed during the day on multiple observations. The resident was observed in her room in bed wearing a hospital gown on 1/5/26 at 11:21 a.m., on 1/6/26 at 9:35 a.m. and 11:38 a.m., on 1/7/26 at 9:15 a.m., 11:37 a.m., and 1:40 p.m., and on 1/8/26 at 10:42 a.m. and 1:55 p.m. Resident 75 had diagnoses including stroke and dementia without behavior disturbance, and the Annual MDS dated 11/26/25 indicated short- and long-term memory problems, severe impairment in daily decision making, and dependence on staff for upper and lower body dressing. The last care plan review on 12/9/25 did not include a care plan related to wearing a hospital gown while in bed. During interview, the DON stated the care plan would be updated, and later stated the resident's family wanted her to wear a gown when in bed for comfort and that the care plan had been updated.
Failure to Arrange Ophthalmology Referrals and Appointments
Penalty
Summary
The facility failed to ensure that referrals from the optometrist were carried out and that appointments were made for a resident who needed vision services. The resident had diagnoses including end stage renal disease, heart failure, stroke, major depressive disorder, vascular dementia, anxiety, and renal dialysis. The annual MDS indicated the resident was cognitively intact for daily decision making and had adequate vision with no corrective lens, and there was no care plan for vision. An eye exam note documented that the resident had a mild cataract in the left eye and was recommended for YAG laser posterior capsulotomy; the resident wanted to proceed and a referral was written and given to social service. A later eye exam note documented opacification of the posterior capsule in the left eye and a moderate cataract in the right eye, with recommendations for YAG laser posterior capsulotomy and cataract surgery; both referrals were written and given to social service because the resident wanted to proceed. During interviews, the Social Service Director stated she was unaware of both referrals because the Medical Records Supervisor was handling ancillary appointments and social service was not receiving them. The B-Wing Unit Manager stated she tried calling a facility that had previously accepted Medicaid residents, but it was closed indefinitely, then searched for other eye surgeons who did not accept the resident's insurance. The SS Assistant stated she had not contacted the ombudsman or the Corporate Social Service Director for resources.
Failure to Document Tube Feedings and Provide Ordered PEG Site Care
Penalty
Summary
The facility failed to ensure bolus tube feeding administration was documented as completed for a resident with a PEG tube, stroke, dysphagia, and dementia who was NPO and receiving tube feedings. The resident’s record showed orders allowing bolus feedings if feeding bags were unavailable, and nursing notes indicated bolus tube feeding and flushes were being used because of PEG port issues. However, the December 2025 and January 2026 MARs did not contain documentation that the bolus tube feedings were administered, and the DON stated the feeding and the amount instilled should have been documented. The facility also failed to provide ordered PEG tube site care for another resident with a feeding tube, diabetes, and lupus. The resident had a physician’s order for mupirocin-lidocaine ointment to the G-tube site three times daily, with cleansing and application for 14 days, but the site was observed with a soiled dressing, redness, tan/yellow drainage, and thicker brown drainage on the dressing and abdomen. The dressing and site remained unchanged across multiple observations, and later the site had no dressing, scant dried drainage, and no visible ointment. An LPN stated he did not perform the PEG tube care that morning even though he signed it out on the MAR, and the DON was informed of the findings.
Failure to Document PICC Line Measurements
Penalty
Summary
The facility failed to document PICC line measurements as ordered for Resident 161, who had diagnoses including unspecified severe protein-calorie malnutrition, colostomy, and intestinal obstruction. The resident’s admission Skilled Evaluation noted that the resident was alert and oriented and had a PICC line. A physician’s order directed staff to measure the PICC catheter length on admission and with each dressing change thereafter, every Sunday night. The MAR showed PICC line dressing changes on 12/24/25, 12/28/24, 12/31/24, and 1/4/26, but the record lacked documentation of PICC catheter length measurements. The care plan identified the resident as at risk for infection related to having a PICC line and included dressing changes as ordered with measurements of the external catheter length and arm circumference 10 cm above the insertion site. During interview, the Nurse Consultant stated she reviewed the record and did not find any documentation of PICC length measurements.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure oxygen was flowing at the correct rate per minute for one resident who was reviewed for oxygen therapy. Resident 14, who had diagnoses including COPD, paranoid schizophrenia, intellectual disabilities, asthma, psychotic disorder, and high blood pressure, was observed multiple times in bed while wearing oxygen on the room concentrator at 1.5 liters per nasal cannula. The resident’s care plan, revised on 10/23/25, indicated oxygen therapy related to COPD and directed staff to set oxygen per physician’s order. However, the physician’s order dated 10/16/25 specified oxygen at one liter per nasal cannula and to keep oxygen saturation about 90%. During observation on 1/8/26, RN 1 saw the oxygen set at 1.5 liters and stated she was unaware of what the resident’s oxygen should be set at. The B-Wing Unit Manager later stated the oxygen should be on the current liters per minute as ordered.
Failure to Monitor Blood Sugar and Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure insulin was administered as ordered and that blood sugars were monitored for one resident with type 2 diabetes. The resident’s record showed a Quarterly MDS assessment indicating the resident was not cognitively intact for daily decision making and received insulin, and the care plan identified diabetes mellitus with an approach to check blood sugar as ordered by the physician. A physician’s order directed Insulin Glargine 15 units subcutaneously every morning and at bedtime, with instructions to hold the dose if blood sugar was less than 100. However, the MAR for 11/2025 and 12/2025 showed the Glargine insulin was administered at bedtime, and there was no documentation that blood sugar was checked on several dates. During interview, the Nurse Consultant stated there were no blood sugars available for review for those dates.
Improper Mechanical Lift Transfer and Missing Floor Mat for Fall Risk Resident
Penalty
Summary
The facility failed to ensure a resident was transferred properly in a mechanical lift. Resident B had diagnoses including Alzheimer’s disease, dementia without behaviors, hypertension, major depressive disorder, anxiety, and osteoarthritis. The resident’s MDS indicated severe impairment in daily decision making and dependence on staff for bed-to-chair transfers. The care plan directed staff to provide assistance with transfers and required use of a mechanical lift, and the resident was receiving hospice services. During the early morning transfer, a CNA and another staff member were using a Hoyer lift when the resident slipped out of the Hoyer pad and fell to the floor. Staff statements and interviews described that the resident was being transferred when one CNA left the room to assist elsewhere, and within seconds the resident slid out of the pad. The resident was found on the floor on his right side with tenderness near the right rib area. The resident was then placed back into bed using the Hoyer lift with three staff members. The facility’s records also contained statements indicating the resident had been transferred improperly and that the CNA admitted to improper use of the Hoyer during the transfer. The facility also failed to ensure a floor mat was in place for Resident C, who had diagnoses including right femur fracture, dementia, anxiety, repeated falls, major depressive disorder, Alzheimer’s disease, and osteoarthritis. The resident’s MDS showed moderate impairment in daily decision making, dependence on staff for transfers, and substantial to maximal assistance needed for bed mobility. The care plan identified the resident as at risk for falls and directed staff to place a mat on the floor beside the bed. However, repeated observations showed the resident in bed with the bed in a very high position and no floor mat beside the bed. The resident had previously been found on the floor next to the bed and later hospitalized with a right neck femur fracture.
Lack of Social Services Follow-Up and Documentation
Penalty
Summary
The facility failed to provide medically related social services for a resident with multiple diagnoses including cancer, heart failure, hypertension, end stage renal disease, diabetes mellitus, thyroid disorder, anxiety, depression, chronic obstructive pulmonary disease, and metabolic encephalopathy. The resident’s MDS indicated she was cognitively intact, but a behavior charting note documented that she repeatedly called 911 stating, “we are breaking into her house.” Interventions such as redirection and offering a beverage or snack were attempted, and she was later taken to the nurse’s station, but the record lacked documentation that Social Services followed up on the behavior or the 911 calls. The record also lacked documentation of Social Services follow-up related to an abuse allegation and a missing cell phone. An Indiana Department of Health facility-reported incident stated the resident reported at a doctor’s appointment that she had been hit by a staff member and that her cell phone was stolen. The incident record noted the allegation was investigated and found unsubstantiated, with no bruising or harm observed and no cell phone confirmed in the resident’s inventory or by family. However, there was no documentation that Social Services interviewed the resident or completed follow-up regarding the allegation or the missing cell phone. For another resident with dementia, anemia, hypertension, neurogenic bladder, hyperlipidemia, and adult failure to thrive, Social Services faxed a referral to another nursing home at family request and later called the receiving facility, but there was no further documentation of correspondence, acceptance, or whether additional information was needed.
Failure to Provide Timely Anti-Seizure Medication
Penalty
Summary
The facility failed to ensure that anti-seizure medication was available and administered according to physician's orders for one resident with a diagnosis of seizures. The resident had a physician's order for lacosamide 50 mg to be given every morning and at bedtime. Review of the medication administration record for October showed that the bedtime dose on 10/24 and the morning dose on 10/25 were not documented as administered. A progress note indicated that the medication was unavailable at the time, and the pharmacy required a new prescription. The Corporate Nurse Consultant confirmed that the medication was supplied on a card from the pharmacy, allowing nurses to see when a refill was needed, and that the pharmacy had a prescription with refills available, but the medication was not received until after the resident had transferred out of the facility.
Failure to Ensure Timely Medical Appointments for a Resident
Penalty
Summary
The facility failed to ensure that medical appointments for a resident were completed in a timely manner, resulting in the resident not being seen by a neurologist since admission. The resident, who had a history of stroke, aphasia, hemiplegia, hemiparesis, seizures, and altered mental status, was cognitively impaired for daily decision-making. A physician's order dated 3/8/24 required an appointment with a neurologist to be scheduled in one month, but multiple attempts to fulfill this order were unsuccessful due to various logistical issues. The resident's appointments were repeatedly rescheduled due to transportation issues, such as the transportation not showing up, the resident's wheelchair not fitting through the office doors, and errors in scheduling the appointment dates. Despite several physician's orders and attempts to schedule the appointments, there was no documentation indicating that the resident was seen by a neurologist on the scheduled dates. The Executive Director acknowledged that alternative measures should have been attempted to ensure the resident was seen by the neurologist.
Failure to Offload Heels for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services to promote healing, specifically related to offloading heels while in bed. Observations over several days revealed that the resident's heels were not offloaded and were lying directly on the mattress, contrary to the care plan and physician's orders. The resident, who was not cognitively intact for daily decision-making, had a pressure ulcer on the left heel with black and dark maroon intact tissue and flaking surrounding skin. The care plan indicated the need to float the heels, and the physician's orders specified offloading the heels at bedtime for skin integrity. The resident's medical history included conditions such as urine retention, anemia, high blood pressure, obstructive uropathy, anxiety, schizophrenia, mood disturbance, dementia, and depression. A wound nurse practitioner had recommended treatment for a deep tissue injury on the left heel, including applying skin prep and floating the heels with heel boots. Despite these recommendations, the facility did not consistently implement the necessary measures to offload the resident's heels, as confirmed by the wound nurse and the executive director during interviews.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a call light was within reach and that preventative fall measures were in place for two residents identified as being at risk for falls. Resident C was observed in her room with her call light on the floor underneath her bed on multiple occasions, despite her care plan indicating that the call light should be within easy reach due to her history of falls and weakness. The resident was cognitively intact and required substantial assistance with mobility, yet the call light was not accessible, which was acknowledged by the Executive Director. Resident D was observed lying in bed with the bed in a high position and no floor mat on the ground, contrary to the care plan that required a floor mat and a low bed position due to the resident's confusion and poor safety awareness. Despite physician's orders and the treatment administration record indicating the necessity of a floor mat for fall prevention, it was not in place. Staff interviews revealed that the mat was kept in the closet to prevent the ambulatory roommate from tripping, which was known to the ACU Unit Manager and CNA. The Executive Director provided no additional information regarding this oversight.
Improper Foley Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with a Foley catheter, as observed during multiple instances where the catheter bag and tubing were not maintained according to professional standards. On several occasions, the catheter bag was seen resting on the floor, both when the resident was in a wheelchair and when in bed. The catheter bag was also observed hanging above the resident's waist, contrary to the care plan's instructions to keep it below the bladder level and off the floor. These observations were made despite the resident's care plan, which emphasized the importance of maintaining the catheter bag below the bladder level to prevent urinary tract infections. Resident D, who was not cognitively intact for daily decision-making, had a history of chronic urinary tract infections and was diagnosed with conditions such as urine retention and obstructive uropathy. The facility's policy on indwelling catheter use and removal required adherence to professional standards, including keeping the catheter bag below the waist and off the floor. Interviews with staff revealed awareness of the issue, with instructions given to place the catheter bag in a basin when the bed was in a low position. However, these instructions were not consistently followed, leading to the deficiency.
Oxygen Flow Rate Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that a resident's oxygen was set at the correct flow rate, as observed during multiple random checks. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease (COPD) and high blood pressure, was prescribed continuous oxygen at 2 liters per minute per nasal cannula according to a physician's order dated April 30, 2024. However, during observations on August 19, 22, and 23, 2024, the resident was seen with the oxygen flow rate set just under 3 liters per minute. Despite this, the Medication Administration Record (MAR) for August 2024 indicated that the oxygen was documented as being administered at 2 liters per minute on several dates. Interviews with the Executive Director and a Qualified Medication Aide (QMA) confirmed that the oxygen should have been set at the prescribed 2 liters per minute.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection control guidelines during a medication pass, as observed on August 22, 2024. An LPN was seen using reusable instruments to check the blood pressure, pulse, and temperature of Resident 71. After completing the checks, the LPN returned the instruments to the medication cart without sanitizing them. She then proceeded to administer medication to Resident 71 and moved to Resident 53's room, where she used the same unsanitized instruments to check his vital signs. It was only after checking Resident 53's vital signs that the LPN cleaned the devices with a germicide wipe. During an interview, the LPN acknowledged the requirement to clean and sanitize reusable equipment after each use. The facility's policy on cleaning and disinfection of resident-care equipment, provided by the Executive Director, mandates that staff follow infection control principles, including cleaning and disinfecting multi-resident items after each use. Despite this policy, the LPN did not sanitize the equipment between uses for different residents, leading to a breach in infection control protocols.
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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 Portage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miller's Merry Manor | 0.5 mi | ★★★★★ | 18 | 0 |
| Waters Of Hobart Skilled Nursing Facility, The | 5.6 mi | ★★★★★ | 0 | 0 |
| Casa Of Hobart | 7.1 mi | ★★★★★ | 27 | 0 |
| Chesterton Manor | 7.2 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Chesterton | 7.2 mi | ★★★★★ | 27 | 0 |
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