Below average — CMS composite of the measures below.
The next survey window likely opens 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 - Richmond Care Center during CMS and state inspections, most recent first.
Call lights and fluids were not kept within reach for three residents. One resident was found with the call light out of reach and no fluids in the room, another had the call light behind the headboard and no water at bedside, and a third also had no fluids available and had to use the call light to request a drink. Records showed each resident had care plans or orders for fluids and/or call light access, and one resident had dry mouth and lips during observation.
Failure to file a grievance for missing resident clothing. A cognitively intact resident with hemiplegia and hemiparesis reported two missing sweaters, including one valued at over $100 and another received as a gift, but no grievance was documented. The ED and a laundry/housekeeping aide both acknowledged the issue was discussed and that a grievance form should have been completed, but no follow-up occurred.
Call Light Not Kept Within Reach and Touch Call Light Not Implemented: A resident at high fall risk had a care plan that included keeping the call light within reach, prompt response to requests, and a touch pad call light, but staff observed the call light out of reach during one check and later verified the resident still did not have a touch pad call light. The resident had multiple diagnoses, was moderately impaired for daily decision making, required substantial/maximal assist with transfers, did not ambulate, and had a recent fall with injury.
Failure to Start Ordered Eye Drops: A resident with cataracts was seen by an optometrist who ordered Refresh Dry Eye Therapy drops, but the order was not entered into the chart and the resident did not begin receiving the medication. Interviews showed SSD handled the eye visit paperwork, while nursing did not receive the consult note or orders, and the resident reported ongoing eye discomfort.
Failure to Provide Ordered Elbow Splint Assistance: A resident with contractures and R-sided hemiplegia did not receive the elbow splint assistance required by the restorative nursing plan. The EHR showed the splint intervention was missed multiple times, the resident was not wearing the splint during observation, and the RNA stated she had not offered it because she was unaware he had one. The TD later found the elbow splint in a nightstand behind the bed.
A resident with edentulous status and improperly fitting dentures reported that his dentures were too big, had not fit for a long time, and were kept in a bathroom cup while he remained without dentures in his mouth. Records showed the resident had not had documented dental follow-up since the last dental note, despite a care plan for dental coordination and a DON policy for routine dental services, and the SSD stated there was no documentation that the facility contacted the dentist to schedule an appointment.
A resident with a documented history of inappropriate sexual behaviors was assigned a roommate and later entered another resident's room, where he made repeated sexual comments, asked for sexual acts, watched the roommate while toileting, and allegedly touched another resident inappropriately. The roommate reported feeling upset and gross, and the other resident stated he was touched under his pants and on his private part. Staff interviews showed they were unaware of the resident's behavior management interventions and no added supervision was in place when the roommate assignment occurred.
Failure to implement behavioral health interventions for a resident with Wernicke’s Encephalopathy and Substance Abuse Disorder. The care plan documented inappropriate touching, self-pleasuring, and loud inappropriate comments, with interventions to keep distance, redirect behaviors, and monitor needs. However, the SSD, CNAs, and an LPN were unaware of the resident’s behavior management interventions, and one staff member did not know about the self-pleasure behaviors or any added supervision when the resident had a roommate.
A resident with multiple comorbidities and high fall risk, requiring substantial assistance for transfers, was injured when a CNA transferred her without a gait belt or mechanical lift, contrary to care plan instructions. The resident's leg was lacerated on exposed metal from a wheelchair, resulting in a wound requiring 18 sutures. The incident was attributed to inadequate supervision, improper transfer technique, and unsafe equipment.
A resident with multiple psychiatric and medical diagnoses was found deceased in his room, and staff verified his DNR status and lack of vital signs. However, the facility did not document the death, notifications to the physician or family, or the disposition of the resident's body and belongings in the clinical record, contrary to facility policy. Leadership stated this was a deliberate decision made with legal counsel due to the stressful circumstances.
The facility failed to date and identify open medication bottles in two medication carts, with several bottles lacking open dates and some medications being unidentified. Loose pills and an unlabeled inhaler were also found. Staff interviews revealed uncertainty about medication origins and confirmed that open dates should be marked. The DNS stated that nursing staff are responsible for labeling, with a binder available for discard time lengths.
A facility failed to ensure the interdisciplinary team (IDT) determined and documented the clinical appropriateness of self-administration of medications for a resident. The resident, who was cognitively intact, was found with a pill and Visine eye drops at her bedside, which she did not want or request. An LPN confirmed the resident should not have medications at the bedside, and the Director of Nursing Services confirmed there was no self-administration order or care plan in place.
The facility failed to ensure proper documentation of code status and care plans for two residents. One resident had conflicting information between the POST form and care plan, while another resident's code status was not documented at all. The DNS acknowledged these discrepancies, which were not in line with the facility's policy on code status communication.
The facility breached resident privacy by allowing staff to use personal cell phones to capture images and videos of residents' medical conditions. An LPN took a picture of a resident's wound, and another recorded a video of a resident's behavioral change, both sent to the DNS for further guidance. This action violated the facility's policy on resident privacy.
The facility failed to ensure resident safety by not enforcing the use of smoking aprons for residents identified as needing them. A resident with chronic respiratory issues and two others with mobility impairments were observed smoking without aprons, contrary to their care plans. Despite assessments indicating the need for aprons, residents admitted to not consistently wearing them, and the facility's policy was not adequately enforced.
The facility failed to obtain physician orders for crushing medications for three residents, despite the practice being carried out based on nursing judgment. Residents with conditions such as diabetes and chronic obstructive pulmonary disease were receiving crushed medications without proper orders, contrary to the facility's policy. A nurse reported the issue to the Director of Nursing and Executive Director, but no corrective actions were taken.
A resident experienced a severe change in condition, exhibiting unusual behaviors and was administered Ativan without proper documentation of its indication or follow-up on its effectiveness. Despite attempts by an LPN to alert the DNS, the resident's condition worsened, leading to hospitalization where toxic encephalopathy due to drug use was diagnosed.
A facility failed to ensure a hospice order and care plan for a resident with anxiety disorder, diabetes, and chronic pain syndrome. The resident was placed on hospice, but the EHR lacked a hospice order and care plan. The DNS noted a one-time hospice consult order was not followed up, and a recent care plan library switch caused old plans to disappear. A hospice care plan was created later to coordinate care and obtain necessary orders.
A resident with chronic respiratory issues was found to have two medicated nasal sprays at their bedside without a prior self-administration assessment. Despite being cognitively intact, the facility did not complete the required assessment before allowing the resident to self-administer medications, as per their policy.
A resident with multiple medical conditions, including dysphagia and a history of pressure ulcers, did not receive fresh water daily as required. Observations showed the resident only had thickened juice and coffee available, despite expressing a preference for water. The care plan included encouraging fluid intake due to risks of constipation and elimination issues, but the facility staff failed to provide fresh water, as confirmed by the DON.
A facility failed to use PPE for a resident in contact isolation due to suspected ringworm. Despite clear signage, two CNAs entered the resident's room without gowns or gloves, unaware of the isolation status. The unit manager confirmed the need for precautions, and the DNS noted unsuccessful treatments for the resident's condition. The nurse practitioner later discontinued isolation after observing improvement with OTC cream.
The facility failed to follow physician orders for obtaining weights for two residents and conducting accurate skin assessments for another. One resident was not weighed for four months, and another experienced significant weight gains without provider notification. Additionally, a resident with a history of pressure ulcers did not have heels floated as required, and a rash was not treated after the initial period. Interviews revealed a lack of adherence to care plans and physician orders by staff.
The facility failed to conduct regular care plan meetings for two residents, one with cerebral palsy and autism, and another with intellectual disabilities and depression. Despite the policy requiring quarterly meetings, documentation showed gaps in scheduling, indicating non-compliance with care planning protocols.
A facility failed to notify a resident's infectious disease physician of lab results and did not obtain a lab as ordered before continuing antibiotic administration. The resident, with a history of osteomyelitis, was to receive Vancomycin with weekly lab tests, but the results were not consistently communicated. A high Vancomycin trough result was not reported, and the facility relied on the pharmacy for dosing management, which was not always followed. The resident filed a grievance regarding medication issues, leading to the discontinuation of Vancomycin.
A facility failed to ensure a staff member followed policies for the safe use of a mechanical lift, requiring two staff members for operation. This resulted in a resident falling and fracturing her knee during a transfer. The CNA involved was suspended and terminated for not adhering to the policy.
The facility failed to develop and implement a care plan for a resident experiencing seizure-like activities, despite multiple documented incidents and a fall. The DON confirmed the absence of a care plan, which is required by the facility's policy on comprehensive care plans.
The facility failed to provide timely and consistent wound care for two residents, leading to the worsening of pressure ulcers and subsequent hospitalizations. One resident developed an unstageable pressure ulcer that became infected, while another progressed to a stage 3 pressure ulcer due to inadequate treatment and documentation.
Call Lights and Fluids Not Kept Within Reach
Penalty
Summary
The facility failed to reasonably accommodate residents’ needs and preferences by not ensuring call lights and fluids were within reach for 3 of 3 residents reviewed. During observations, Resident 41 was found lying in bed with the call light out of reach on a recliner under a blanket, and no fluids were available in the room. The resident’s mouth and lips were dry, and the resident stated that sometimes staff gave fluids and sometimes they did not. A CNA later provided the call light and a cup of ice water, which the resident drank independently. Resident 10 was observed lying in bed with the call light behind the headboard on the floor, and no water was available at the bedside; only a cup of coffee was present and out of reach. A CNA entered the room and provided the call light. The resident later stated that it happened frequently that she did not have water available and sometimes her call light was out of reach, and that she would sometimes rely on her roommate to use the call light for her. Her record showed diagnoses including COPD, anemia, anxiety, arthritis, hypertension, muscle weakness, and dementia, and she required set up only for drinking. Resident 5 was observed without fluids available in the room and stated that staff occasionally did not provide fluids. The resident activated the call light and requested something to drink. The resident’s record showed diagnoses including depression, muscle weakness, diabetes, anxiety, and vitamin deficiency, and the resident required set up for eating and drinking fluids. Facility policies provided by the DON stated that beverages should be available and within reach and that call lights should be at each resident’s bedside and accessible while in bed.
Failure to File Grievance for Missing Resident Clothing
Penalty
Summary
The facility failed to file a grievance for a resident’s missing clothing, specifically two sweaters, for 1 of 1 resident reviewed for grievances. Resident 34 was cognitively intact and had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, as well as dry eye syndrome. During interview, the resident stated that two sweaters had been missing for approximately three months, including a gray sweater that cost over $100 and had been given by his step-daughter, and a green sweater received the previous Christmas. He said he told the Executive Director about the missing items about a month earlier and was told they would look for them and get back with him, but no one followed up with him afterward. Review of grievances for the prior six months showed no grievance had been filed regarding the missing sweaters. The Executive Director stated the resident had mentioned the missing sweaters while passing by and that he assumed the matter had been handled after the resident said he had spoken with Laundry/Housekeeping Aide 2. The Executive Director acknowledged he did not follow up with the resident and said he should have filled out a grievance for the missing items. Laundry/Housekeeping Aide 2 stated the resident reported the missing sweaters, that she and the resident’s wife looked in the laundry room without finding them, and that she told the Executive Director, who said he would follow up with the resident. She also stated she never heard anything else about the missing sweaters and said she should have filled out a grievance form when first told about the missing items.
Call Light Not Kept Within Reach and Touch Call Light Not Implemented
Penalty
Summary
The facility failed to ensure care plan interventions were implemented for a resident’s call light to be within reach and failed to implement a touch call light for a resident at high risk for falls. During an observation and interview on 12/02/2025 at 2:08 p.m., Resident 41 was lying in bed and the resident’s call light was out of reach, located on a recliner underneath a blanket; the call light was activated for a test. A CNA entered the room and stated he was responsible for ensuring the resident had her call light within reach, and explained he had assisted the resident to lie down, then forgot to give her the call light after the roommate requested something. The CNA then provided the resident with her call light. During another observation and interview on 12/04/2025 at 2:34 p.m., Resident 41 was lying in bed with her call light, and a CNA verified the resident did not have a pad touch call light. The record showed the resident’s diagnoses included history of UTI, muscle weakness, age-related debility, CKD, constipation, and major depression. The fall care plan dated 8/5/25 identified the resident as at risk for falls related to deconditioning and history of falls, with interventions including ensuring the call light was within reach, encouraging use for assistance, prompt response to requests, and a touch pad call light. The quarterly MDS dated 10/15/25 showed the resident was moderately impaired for daily decision making, required substantial/maximal assistance with transfers, did not ambulate, and had one fall with injury since the prior assessment. The fall risk assessment dated 11/9/25 indicated the resident was at high risk for falls, and the facility’s fall prevention policy stated residents would receive care and services according to individualized fall risk, including call light and frequently used items within reach and alternate call system access.
Failure to Start Ordered Eye Drops
Penalty
Summary
The facility failed to initiate continuation of care for Resident 9’s comfort eye drops after an optometry visit. Resident 9’s record showed diagnoses including cataracts, and her impaired visual function care plan identified a goal of having no indications of acute eye problems, with an intervention to arrange consultation with the eye care practitioner as required. The physician’s orders allowed her to see an ophthalmologist and/or optometrist, and she reported that she had seen the optometrist a couple of weeks earlier, who ordered eye drops for her, but she had not yet begun receiving them. The optometry consultation note documented a new medication order for Refresh Dry Eye Therapy solution, one drop in both eyes twice daily indefinitely, and stated that there were new orders requiring action by nursing home staff. However, the physician’s orders in the clinical record did not include the Refresh eye drops. Interviews showed that social services handled eye doctor visits, nursing did not receive the orders or consultation notes, and staff were unsure what happened with the ordered drops. Resident 9 later stated she still had not begun receiving the eye drops and that her eyes felt like they had sand in them.
Failure to Provide Ordered Elbow Splint Assistance
Penalty
Summary
The facility failed to offer a resident his elbow splint, as required by the restorative nursing plan, for 1 of 2 residents reviewed for positioning and mobility. The resident had diagnoses including contractures and right-side hemiplegia. His restorative nursing PROM care plan, revised on 12/2/25, directed staff to provide PROM to the right upper extremity and PROM/stretch of the right elbow and hand in preparation for donning a splint, and to assist with an orthotic elbow extension splint and carrot or palm guard to the right upper extremity for up to 2 or more hours daily, 6 days per week. The electronic health record showed the splint intervention was not completed 8 of the last 30 days, with no documentation that the resident refused or was unavailable. During observation, the resident was not wearing an elbow splint and stated he did not use one, only the carrot for his hand. No elbow splint was visible in his room until the TD retrieved it from a nightstand behind the bed during the observation with the TD and RNA. The RNA stated she had not offered the elbow splint because she was unaware the resident had one. The TD and UM stated therapy oversaw and implemented the restorative nursing/PROM program, and the facility policy stated the restorative nurse was responsible for maintaining the current list of residents needing restorative services and ensuring all elements of each resident's program were implemented.
Failure to Provide Routine Dental Services for Resident with Improperly Fitting Dentures
Penalty
Summary
The facility failed to provide routine dental services for a resident who had improper fitting dentures. During an observation and interview, the resident stated he had dentures but they were too big, were kept in his bathroom, and had not fit him for a long time. He said he would like dentures that fit and reported he did not have trouble eating, but he missed foods such as corn on the cob because he did not have dentures that fit. The dentures were observed in a denture cup in the bathroom, and the resident was observed without dentures in his mouth. Record review showed the resident’s diagnoses included depression, muscle weakness, diabetes, anxiety, and vitamin deficiency. The last dental note, dated 11/2/23, indicated the resident was edentulous, had poor oral hygiene, and was recommended for routine dental exams. The annual and quarterly MDS assessments indicated the resident had no natural teeth, was edentulous, and was cognitively intact for daily decision making. The care plan identified a potential for oral problems related to edentulous status and included coordination for dental care and transportation as needed, but the Social Service Director stated there was no documentation that the resident had seen a dentist since 11/2/23 and no documentation that the facility had contacted the dentist to schedule an appointment after that visit.
Failure to Protect Residents from Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to protect residents from sexual abuse and inappropriate sexual behaviors involving a resident with a documented history of inappropriate conduct. Resident E had diagnoses including Wernicke's encephalopathy and substance abuse disorder, and the record showed repeated behaviors such as grabbing staff in inappropriate areas, wanting to lay his head on other residents' shoulders, self-pleasuring in the room with a roommate present, making vulgar sexual comments, and asking other residents for fellatio. His care plan included interventions such as redirecting inappropriate touching and maintaining appropriate distance, but staff interviews showed they were unaware of these behavior management interventions and did not increase supervision when he was assigned a roommate. Resident F, who was cognitively intact and had diagnoses including spinal stenosis and major depressive disorder, was moved into Resident E's room. After the room change, Resident F reported that Resident E repeatedly asked him to show his penis, made comments about his butt, and watched him while toileting. Resident F stated these behaviors upset him and made him feel gross. The DON confirmed there were no additional interventions or increased supervision when Resident F was placed in Resident E's room. Resident D, who had intellectual disabilities and anxiety and required partial to moderate assistance with dressing and transferring, reported that Resident E entered his room and touched him inappropriately. Resident D stated that Resident E touched him under his pants with his hand and touched his private part. A staff statement also noted Resident E was acting suspicious near Resident D's room before the incident. The nursing note documented that the accused resident was immediately removed and placed on 1:1 supervision after Resident D reported the inappropriate touching.
Failure to Implement Behavioral Health Interventions
Penalty
Summary
The facility failed to ensure that Resident E received necessary behavioral health care and services. Resident E’s clinical record showed diagnoses of Wernicke’s Encephalopathy and Substance Abuse Disorder, and the care plan documented behaviors including grabbing staff in inappropriate areas, laying his head on other residents’ shoulders, self-pleasuring in the room with a roommate present, and making loud inappropriate comments to staff and other residents. The care plan interventions included administering medications, monitoring effectiveness, anticipating needs, keeping appropriate distance when communicating, redirecting attempts to lay on staff shoulders, and redirecting inappropriate touching. Staff interviews showed they were not knowledgeable about the resident’s behavioral interventions. The SSD stated she was not aware of the self-pleasure behaviors, was not aware of any new interventions when the resident obtained a roommate, and did not increase supervision. CNA 3 was unaware of the interventions to keep distance when interacting with the resident. LPN 4 stated she was unaware of any behavior management interventions and would only assure safety and notify the DON/ED if behaviors occurred. CNA 5 was also unaware of the behavioral management interventions, including redirecting and keeping distance when communicating with the resident. The staff management system listed behavioral interventions such as educating the resident to avoid inappropriate or sexual behaviors, arranging mental health services, and providing opportunities to express mental health needs.
Failure to Provide Safe Transfer and Supervision Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who required more than limited assistance with transfers did not receive adequate assistance and supervision, resulting in a significant injury. The resident, who had multiple diagnoses including metabolic encephalopathy, chronic kidney disease, vascular dementia, and was at high risk for falls, required substantial to maximal assistance for transfers and used a wheelchair. Despite care plan interventions indicating the need for extensive assistance from one to two staff and the possible use of a sit-to-stand lift during periods of increased weakness, the resident was transferred by a single CNA without the use of a gait belt or mechanical lift. During the transfer, the CNA lifted the resident under the arms at the resident's request, rather than using the sit-to-stand lift as directed. The resident lost balance and struck her left lower leg on the bed frame or wheelchair, resulting in a large laceration that required emergency medical attention and 18 sutures. The resident reported significant pain following the incident. Interviews with staff and the resident confirmed that the transfer was not performed according to policy or the resident's care plan, and that the wheelchair had a sharp exposed metal edge due to a missing rubber/plastic piece. Further review revealed that the facility's safe resident handling and transfer policy required the use of appropriate assistive devices and adherence to the resident's individual care plan. However, the resident's care plan did not specify transfer instructions until after the incident. The lack of proper supervision, failure to use required equipment, and the presence of a hazardous wheelchair contributed directly to the resident's injury.
Failure to Document Resident Death and Related Notifications
Penalty
Summary
The facility failed to document the death of a resident in the clinical record, including the notification of the resident's death to the physician, family, or responsible party, as well as the disposition of the resident's body, personal possessions, medications, and a complete and accurate notation of the resident's condition preceding death. Interviews with staff revealed that the resident, who had diagnoses including dementia, psychotic disturbance, bipolar disorder, depression, suicidal ideations, and anxiety disorder, was found deceased in his room with a plastic bag over his head. Staff confirmed the resident's Do Not Resuscitate (DNR) status and verified the absence of pulse and respirations. Despite these events, there was no documentation in the clinical record regarding the circumstances of the resident's death or the actions taken afterward. The last entry in the resident's record was made earlier that day by the Social Service Director, noting the resident was asleep and the room was orderly. Facility leadership, including the DON and the facility president, indicated that the decision not to document the death was made in consultation with the legal department, citing concerns about accuracy in a high-stress situation. The facility's own policy requires timely, accurate, and complete documentation of resident experiences and care, which was not followed in this instance.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that open medication bottles were properly dated and identified in two medication carts observed during a survey. Several medication bottles, including Guaifenesin, Enulose, Polyethylene Glycol, Milk of Magnesia, oral simethicone, Dermal Wound Cleanser, and Refresh Optive Advanced, were found without open dates marked on them. Additionally, a Fluticasone Propionate inhalation powder lacked a resident label or dates, and a loose orange oblong pill was found in the medication drawer. During an interview, a registered nurse indicated uncertainty about the origin of the open pill and acknowledged that open dates and expiration dates should be marked on new medication bottles. In another observation, a loose blue pill was found in a medication drawer, and an Albuterol inhaler with no resident label was discovered in the bottom drawer. The licensed practical nurse was unsure of the medication's ownership and confirmed that open medications should not be stored in the cart. Further inspection revealed additional medication bottles without open dates, including Enulose, Guaifenesin, Max Tussin, Milk of Magnesia, Polyethylene Glycol, and Potassium Chloride. The Director of Nursing Services confirmed that nursing staff are responsible for marking open and dispose dates on new medication bottles, and a binder at the nurses' stations provides discard time lengths for different medications.
Failure to Ensure IDT Approval for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) determined and documented the clinical appropriateness of self-administration of medications for Resident T. The resident, who was cognitively intact for daily decision-making as per the Annual Minimum Data Set (MDS) assessment, was observed with a blue oblong pill in a medicine cup at her bedside, which she did not want but did not communicate to the nurse. Additionally, a bottle of Visine eye drops was found on her bedside table, which the resident indicated was left by a nurse. Licensed Practical Nurse (LPN) 3 confirmed that Resident T should not have any medications at the bedside and was unaware of who left them there. The Director of Nursing Services (DNS) also confirmed that there was no self-administration of medication order or care plan in place for Resident T. The facility's policy requires that a resident may only self-administer medications after the IDT has determined it is safe, which was not followed in this case.
Failure to Document Code Status and Care Plans
Penalty
Summary
The facility failed to ensure proper code status orders and care plans for two residents, Resident EE and Resident GG. Resident EE's clinical record showed a discrepancy between the Physician Orders for Scope and Treatment (POST) form, which indicated a Do Not Resuscitate (DNR) status, and the care plan, which listed the resident as a full code. This inconsistency was acknowledged by the Director of Nursing Services (DNS), who admitted that the care plan had not been updated properly. For Resident GG, the facility did not have a POST form, code status order, or care plan documented in the clinical record. The DNS explained that Resident GG had not yet decided on her code status, and the facility's practice was to treat such residents as full code until documentation was completed. However, this practice was not in alignment with the facility's policy, which requires clear documentation of code status in the medical record. This lack of documentation was noted during the review, highlighting a failure to adhere to the facility's policy on communicating residents' code status.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical conditions by allowing staff to take pictures and videos on personal cell phones. This deficiency was identified for two residents, referred to as Resident KK and Resident W. In the case of Resident KK, an LPN took a picture of the resident's leg wound on her personal cell phone and sent it to the Director of Nursing Services (DNS) for a second opinion, as she was uncomfortable with the response from the on-call Nurse Practitioner. The LPN later deleted the picture from her phone. Similarly, another LPN recorded a video of Resident W, who was experiencing a significant change in condition, including delusional behavior and self-harm. The LPN sent the video to the DNS after failing to reach her by phone, seeking assistance due to the ineffectiveness of the prescribed medication. The facility's policy, as provided by the Executive Director, explicitly prohibits taking photographs or videos of residents, citing it as a violation of their rights to privacy and confidentiality.
Failure to Utilize Smoking Aprons for Resident Safety
Penalty
Summary
The facility failed to ensure the safety of residents who smoke by not utilizing smoking aprons as required. During observations, it was noted that Resident J, Resident Z, and Resident BB were smoking without wearing smoking aprons, despite their care plans indicating the necessity of such protective measures. Resident J, who has chronic respiratory failure, COPD, and other health issues, was observed smoking without a smoking apron. His care plan, dated 7/9/24, identified him as at risk for smoking-related injury and included the intervention of providing a smoking apron. However, during an interview, Resident J indicated that he did not wear a smoking apron, believing it was only for residents who were unsafe during smoking. Similarly, Resident Z and Resident BB were observed smoking without aprons. Resident Z, who has flaccid hemiplegia and limited range of motion, was assessed to require a smoking apron, yet she admitted to only occasionally wearing one. Resident BB, with moderate cognitive impairment and COPD, also acknowledged wearing a smoking apron sporadically, despite his care plan indicating its necessity. The facility's Director of Nursing Services confirmed that residents who trigger for smoking aprons in their assessments are required to wear them, but this policy was not consistently followed. The facility's smoking policy mandates safety measures for residents who smoke, but these were not adequately implemented for the residents in question.
Failure to Obtain Physician Orders for Crushed Medications
Penalty
Summary
The facility failed to obtain physician orders to crush medications for three residents, identified as Resident L, Resident O, and Resident P, during a survey. Resident L, who has a medical diagnosis of diabetes, reported taking crushed medications since admission, yet there was no active physician order for this practice. Similarly, Resident O, also diagnosed with diabetes, and Resident P, diagnosed with chronic obstructive pulmonary disease, did not have physician orders to crush their medications. A staff member confirmed that medications were crushed based on nursing judgment without physician orders. Registered Nurse (RN) 1 acknowledged issues with medications that could not be crushed and noted that the pharmacy was unaware of the practice due to the lack of physician orders. Despite providing the Director of Nursing Services and the Executive Director with a list of residents receiving crushed medications, no orders were obtained. The facility's medication administration policy requires medications to be crushed only as ordered, highlighting a discrepancy between practice and policy. This deficiency was related to a specific complaint, IN00446364.
Failure to Monitor and Document Medication Use for Resident
Penalty
Summary
The facility failed to adequately monitor and document the use of Ativan, an antianxiety medication, for a resident experiencing an acute change in condition. The resident, who was previously cognitively intact and without hallucinations or delusions, exhibited severe behavioral changes, including making snoring sounds, hitting himself, and tearing up his room. Despite these alarming symptoms, the facility did not document the indication for the Ativan order or follow up on its effectiveness. The Licensed Practical Nurse (LPN) on duty attempted to contact the Director of Nursing Services (DNS) and sent a video of the resident's condition to emphasize the severity of the situation. The resident's condition did not improve after the administration of Ativan, and further symptoms suggested the possibility of unprescribed medication use. The resident was eventually sent to the emergency room, where it was determined that he was suffering from toxic encephalopathy due to cocaine and amphetamine use. The facility's failure to document the purpose and follow-up of the Ativan administration, as well as the lack of immediate and effective intervention, contributed to the deficiency noted in the report.
Failure to Ensure Hospice Order and Care Plan
Penalty
Summary
The facility failed to ensure that an order and care plan were in place for a resident receiving hospice services. Resident DD, who had diagnoses including anxiety disorder, diabetes mellitus, and chronic pain syndrome, was placed on hospice on September 15, 2024. However, the clinical record lacked an order for hospice and a hospice care plan in the Electronic Health Record (EHR). The Director of Nursing Services (DNS) indicated that the resident's physician had initially put in a one-time order for a hospice services consult, which was not followed up with a permanent order. Additionally, the facility had recently switched their care plan library, resulting in the disappearance of old care plans. A hospice care plan was eventually created on November 7, 2024, to coordinate care with hospice services and obtain the necessary physician order and referral.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure that a self-administration of medications assessment was completed for a resident who was reviewed for self-administration of medications. The resident, who was cognitively intact and had no behaviors according to a recent MDS assessment, had chronic respiratory failure and chronic obstructive pulmonary disease. Despite having a care plan initiated to complete a self-administration assessment, the resident was observed with two medicated nasal sprays on their bedside table without an assessment being completed at that time. Interviews and observations revealed that the resident kept the nasal sprays at their bedside, and staff were aware of this arrangement. A QMA confirmed that the resident used over-the-counter nasal sprays provided by their family. It was only after these observations that a self-administration assessment was conducted, which confirmed the resident's capability to self-administer the nasal sprays. The facility's policy required an intradisciplinary team to determine the safety of self-administration before allowing residents to do so, which was not adhered to in this case.
Failure to Provide Fresh Water to Resident
Penalty
Summary
The facility failed to provide fresh water daily to a resident, identified as Resident C, who was reviewed for hydration. Observations and interviews conducted over several days revealed that Resident C consistently had thickened juice and coffee available but no water. The resident expressed a preference for having fresh water daily, which was not being met. On multiple occasions, Resident C indicated she had not received any water in the past five days. Resident C's clinical record indicated several medical conditions, including congestive heart failure, pneumonia, dementia, chronic obstructive pulmonary disease, hypertension, anxiety, dysphagia, and a history of pressure ulcers. The resident was on a regular diet with thickened liquids as per physician orders. The care plan highlighted the risk of constipation and alterations in bowel and bladder elimination, with interventions to encourage fluid intake. Despite these documented needs, the facility's staff did not ensure the provision of fresh water, as confirmed by the Director of Nursing Services.
Failure to Use PPE for Resident in Contact Isolation
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols by not donning personal protective equipment (PPE) before entering the room of a resident who was under contact isolation. The resident, who had a history of hypertension, anxiety, and major depressive disorder, was placed under contact precautions due to a suspected case of ringworm. Despite a sign on the resident's door indicating the need for contact precautions, including the use of gowns and gloves, two certified nurse aides (CNAs) entered the room without the required PPE. CNA 11 entered the room without a gown or gloves, unaware of the resident's isolation status, and CNA 13 also entered without PPE, mistakenly believing the resident was not in isolation after returning from therapy. The unit manager confirmed the resident's isolation status and attempted to educate the staff on the necessary precautions. The Director of Nursing Services (DNS) later revealed that the resident had been treated unsuccessfully for ringworm with various creams since May, and a dermatology appointment was scheduled for December. The nurse practitioner discontinued the contact isolation after realizing the appointment was months away, as the resident's condition seemed to improve with over-the-counter cream. The facility's policy on transmission-based precautions was reviewed, emphasizing the need for PPE to prevent pathogen transmission through direct or indirect contact.
Failure to Follow Physician Orders and Conduct Accurate Assessments
Penalty
Summary
The facility failed to adhere to physician orders for obtaining daily and monthly weights for two residents. Resident 6, who has diagnoses including schizophrenia, muscle weakness, and diabetes mellitus, was not weighed for four months despite a physician order for monthly weights. An abnormal weight was recorded on one occasion, but a re-weigh was not conducted as recommended by the registered dietician. Similarly, Resident 44, who has chronic respiratory failure and uses diuretics, experienced multiple instances of significant weight gain without the provider being notified as required by the physician's order. The facility also failed to conduct accurate skin assessments and follow physician orders for Resident C, who has a history of pressure ulcers and other medical conditions. Observations revealed that Resident C's heels were not floated as required, and the resident was wearing a brief in bed against physician orders. Skin assessments were inconsistently documented, and a rash on the resident's buttocks was not treated with the prescribed cream after the initial treatment period ended. Interviews with the Director of Nursing Services (DNS) and other staff indicated a lack of adherence to physician orders and care plans. The DNS acknowledged the responsibility of direct care staff to obtain weights and notify providers of significant changes, as well as ensuring pressure-relieving devices were in place for Resident C. However, these actions were not consistently carried out, leading to deficiencies in the care provided to the residents.
Failure to Conduct Regular Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for residents and their representatives as required, affecting two out of three residents reviewed. Resident F, who has multiple diagnoses including cerebral palsy, autism, and intellectual disabilities, was admitted on an unspecified date and had only two care plan meetings documented on January 2, 2024, and June 13, 2024. This indicates a lack of regular care plan meetings, which are essential for addressing the resident's complex needs. Similarly, Resident D, with diagnoses including unspecified intellectual disabilities and depression, had a care plan meeting documented on December 12, 2023, with no further meetings recorded. The Executive Director stated that care plan meetings should occur as needed and quarterly, with social services responsible for ensuring their completion. However, the documentation and interviews revealed that these meetings were not held quarterly as required, leading to a deficiency in the facility's compliance with its Care Planning-Resident Participation policy.
Failure to Notify Physician of Lab Results and Manage Antibiotic Administration
Penalty
Summary
The facility failed to notify a resident's infectious disease physician of lab results and did not obtain a lab as ordered by the pharmacy before continuing the administration of an antibiotic for a resident with skin conditions. The resident, who had a history of osteomyelitis, type 1 diabetes mellitus, peripheral vascular disease, and peripheral neuropathy, was admitted to the facility after a hospitalization for osteomyelitis of the right foot. The hospital discharge instructions required the resident to receive Ceftriaxone and Vancomycin for six weeks, with weekly CBC, CMP, and Vancomycin trough tests, and the results were to be faxed to the infectious disease physician. During the resident's stay, the facility's records indicated that the Vancomycin was administered according to orders, but the required lab results were not consistently obtained or communicated to the infectious disease physician. The Vancomycin trough result on 7/2/24 was high, but the physician's office was not notified of this or any other lab results. The facility's Medical Director suggested that the high result might have been due to incorrect timing of the lab draw, and the facility relied on the pharmacy to manage Vancomycin dosing. However, the pharmacy's recommendations were not always followed promptly, and there was no documentation of a Vancomycin trough result for 7/3/24 as recommended by the pharmacy. The facility's policies required prompt notification of lab results outside the clinical reference range to the ordering physician, but this did not occur. The resident's last dose of Vancomycin was administered on 7/8/24, and a grievance was filed by the resident regarding a medication issue. The DON acknowledged the lack of a Vancomycin trough result from 7/3/24 and indicated that the Vancomycin was discontinued after the grievance was filed. The facility's failure to adhere to its policies and the physician's orders led to the deficiency in care for the resident.
Failure to Follow Mechanical Lift Policy Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure a staff member followed policies for the safe use of a mechanical lift, which requires the operation to be conducted by two staff members. This failure resulted in a fall and a fracture for a resident who was being transferred from her chair to bed by a single CNA. The CNA did not secure the resident properly and left the mechanical lift unattended to lower the bed, during which the resident fell and sustained a knee fracture. The resident was sent to the hospital for evaluation and returned to the facility with a knee immobilizer for comfort. The resident involved had multiple diagnoses, including cerebral infarction, diabetes with neuropathy, morbid obesity, and general muscle weakness. She was non-ambulatory, used a wheelchair for mobility, and was dependent on mechanical lifts for transfers. Her care plan indicated that she required two staff members for all transfers using a mechanical lift. The CNA involved had been employed since December 2023 and had completed the necessary training and skills checkoffs for mechanical lift use. The incident was reported to the Indiana Department of Health's Long-Term Care Division, and an immediate investigation was initiated. The facility identified that the root cause of the fall was the CNA attempting to transfer the resident alone, contrary to the facility's policy. The CNA was suspended and subsequently terminated for not following the policy, which contributed to the resident's fall and injury.
Failure to Develop and Implement Care Plan for Seizure-Like Activities
Penalty
Summary
The facility failed to develop and implement a care plan for a resident experiencing seizure-like activities. Resident C, who had diagnoses including unspecified tremor and unspecified convulsions, had documented seizure-like activities on multiple occasions, including at least three on one date and two more on another. One of these seizure-like activities was associated with a fall. Despite these incidents, a review of Resident C's clinical record showed no care plan addressing his seizure-like activities. This deficiency was brought to the attention of the Director of Nursing (DON), who confirmed the absence of a care plan for Resident C's seizures or seizure-like activities. The facility's policy on comprehensive care plans, which mandates the development and implementation of person-centered care plans with measurable objectives and timeframes, was not followed in this case. The lack of a care plan for Resident C's seizure-like activities was identified during a complaint investigation.
Failure to Provide Timely and Consistent Wound Care
Penalty
Summary
The facility failed to ensure timely treatment and services for a resident who was admitted with an identified skin concern, leading to the development of an unstageable pressure ulcer that worsened and became infected. Resident E, who had multiple diagnoses including bipolar disorder, major depressive disorder, and malnutrition, was admitted with a pressure ulcer to the coccyx and lower back. Despite being at risk for pressure ulcer development as indicated by a Braden Scale assessment, the facility did not provide consistent and appropriate wound care. The clinical records showed a lack of proper documentation, inconsistent treatment orders, and failure to follow physician orders, resulting in the worsening of Resident E's condition and eventual hospitalization for a severe infection and Fournier's gangrene extending from a decubitus ulcer and abscess. Another resident, Resident D, who had diagnoses including congestive heart failure and muscle weakness, also did not receive timely and appropriate treatment for incontinence-associated dermatitis (IAD). The resident's condition progressed to a stage 3 pressure ulcer due to the lack of proper wound care and documentation. Despite being identified at risk for pressure ulcer development, there were no physician orders for the treatment of Resident D's skin conditions, and the treatment plans were not consistently followed or documented in the electronic medical records. This neglect led to the deterioration of Resident D's skin integrity and subsequent hospitalization. Interviews with the Director of Nursing (DON) revealed that upon reviewing the residents' charts, significant gaps in wound assessments, treatment orders, and adherence to physician orders were identified. The facility's policy on pressure injury prevention and management was not effectively implemented, leading to the deficiencies observed. The lack of systematic and prompt assessment, treatment, and monitoring of pressure injuries contributed to the adverse outcomes for the residents involved.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 183 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs Of Richmond, The | 2.5 mi | ★★★★★ | 14 | 0 |
| Willows Of Richmond | 2.7 mi | ★★★★★ | 1 | 0 |
| Rosebud Village | 2.7 mi | ★★★★★ | 0 | 0 |
| Forest Park Health Campus | 6.1 mi | ★★★★★ | 12 | 0 |
| Arbor Trace Health & Living Community | 6.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.