Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 - Terrace Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a high risk for falls experienced two falls in one day, yet the care plan was not updated with new interventions as required by facility policy. The ADNS confirmed that no additional fall prevention measures were implemented following these incidents.
A resident with severe cognitive and physical impairments, requiring total assistance with ADLs, had incomplete incontinence documentation, with logs filled out only once per day on several occasions instead of every two hours as required by facility protocol. Staff interviews confirmed the expectation for more frequent checks, but this was not reflected in the records.
Surveyors found that urinals, bedpans, and wash basins were improperly stored in shared bathrooms without required containment, and that an RN failed to change gloves between wound care tasks and after incontinence care for a resident with pressure ulcers. Additionally, another RN did not wear an isolation gown while administering IV medication to a resident on Enhanced Barrier Precautions, contrary to facility policy.
The facility failed to follow physician orders for medication administration, did not consistently monitor or document skin conditions, and did not implement specialist recommendations for several residents. Insulin and blood pressure medications were given outside of ordered parameters, skin issues and frequent diarrhea were not properly documented or treated, and specialist-ordered labs and monitoring were not completed as directed.
A resident with a history of significant weight loss and multiple complex medical conditions, including dysphagia and recent hospitalization, did not have food consumption logs completed for numerous meals as required. Despite the need for close monitoring, documentation was missing for several breakfasts, lunches, and dinners, as confirmed by the DON.
A resident with respiratory failure and COPD was observed receiving oxygen at 3.5 L/min via nasal cannula, despite a physician's order and care plan specifying 2 L/min continuously. The DON confirmed the oxygen should have been set at the lower rate, resulting in a failure to provide respiratory care as ordered.
Surveyors identified failures in medication storage and labeling, including an RN leaving a pre-filled saline syringe unsecured in a resident's room after a PICC line flush, an expired emergency drug kit found in a medication room refrigerator, and an expired vial of insulin on a medication cart. Staff interviews confirmed a lack of awareness and adherence to the facility's medication storage policy.
Two residents were found self-administering medications, including eye drops, an inhaler, and lidocaine patches, without the required physician's orders or assessments for self-administration. One resident was cognitively intact, while the other had severe cognitive impairment. Staff confirmed that neither resident had the necessary documentation to support self-administration, contrary to facility policy.
A resident who was dependent for ADLs and had a history of kidney failure, ileostomy, and falls was left in a soiled bed after her incontinence brief was improperly applied overnight. The resident was unable to get out of bed to eat breakfast as preferred, due to delays in wound care and lack of timely assistance from staff, despite her care plan indicating the need for substantial help with toileting, transfers, and morning routines.
Three residents did not receive prescribed IV antibiotics as ordered, with multiple missed doses and no documentation explaining the omissions. One resident also did not have wound treatments completed and signed out as ordered. The DON confirmed there was no documentation or explanation for the missed medications or treatments.
A resident, who was cognitively intact and not considered at risk for elopement, exited the facility using a door code she learned from her daughter. The staff failed to conduct a head count after an exit alarm sounded, assuming it was related to ambulance activity. The resident was later found off the property with abrasions and was taken to the ER. The facility's policy on elopements was not adequately followed, leading to this incident.
A facility failed to notify all covered individuals of their obligation to report suspected crimes, leading to a deficiency related to an allegation of sexual abuse involving a resident with impaired cognition. The resident reported feeling scared and confused after a male nurse allegedly made inappropriate comments. The dialysis nurse reported the incident to the Dialysis Facility Administrator, who unsuccessfully attempted to contact the facility's DON due to a full voicemail. The facility was unaware of the allegation until the surveyor's investigation, and no annual notifications were sent to covered individuals about reporting obligations.
A resident discharged with orders for IV antibiotics and PICC line care did not receive necessary post-discharge medical care due to incorrect discharge instructions and lack of follow-up by the facility. The resident, who had osteomyelitis, was advised to go to the ER after reporting the issue.
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Residents reported issues with raw and burnt bacon, discolored eggs, and hard sausage patties. The Dietary Food Manager planned to conduct an inservice on cooking and preparing breakfast food.
The facility failed to prepare a pureed diet correctly. A cook was observed adding excessive thickener to a watery cabbage mixture and indicated the recipe would not make enough servings. The DON confirmed the dietary recipe should have been followed.
The facility failed to serve meals as scheduled, causing residents to become impatient. Observations showed significant delays in meal service in both the main dining room and the Memory Lane Unit. Residents also reported consistent delays in meal service during a Resident Council interview. The Administrator confirmed that the dietary staff was a contracted service and meals should have been served on time.
The facility failed to complete self-medication administration assessments for two residents who had medications at their bedside. One resident had a medication cup with a solution, and another had acetaminophen and pain-relieving cream. Both residents were cognitively intact, but there were no assessments or physician's orders for self-administration. The DON acknowledged the oversight.
The facility failed to provide adequate ADL assistance to a dependent resident, specifically in relation to nail care and the removal of facial hair. Despite the resident's care plan indicating an ADL self-care deficit and the need for partial to moderate assistance with personal hygiene, observations confirmed that the resident's nails were long and dirty, and he was unshaven. The DON acknowledged the issue and expected nursing staff to address it.
The facility failed to complete non-pressure skin treatments and ensure the use of TED hose for two residents with edema. One resident had missed applications of prescribed cream, and another was observed multiple times without TED hose, despite physician orders. Interviews revealed a lack of awareness among staff regarding the residents' treatment needs.
A facility failed to ensure that a resident with limited ROM wore ankle braces as ordered. The resident was observed multiple times without the prescribed braces, and the physician's order was not documented in the Medication or Treatment Administration Records. The care plan also lacked information on the use of ankle braces, and the Director of Nursing indicated that therapy was supposed to discontinue the order without proper documentation.
A resident with a history of falls was left alone in the shower room, resulting in a fall due to an unlocked shower chair. The resident required partial assistance with showering, but staff failed to provide adequate supervision, leading to the incident.
A facility failed to ensure proper foley catheter care for a resident, as the catheter bag was observed resting on the floor multiple times. The resident had a history of cerebral palsy, high blood pressure, urine retention, acute kidney disease, and obstructive uropathy, and was being treated for a UTI. The care plan required the catheter bag to be kept off the floor, which was not followed.
The facility failed to ensure correct oxygen flow rates for three residents, with observed rates not matching physician orders. The Director of Nursing acknowledged the discrepancies but had no additional information to provide.
The facility failed to ensure medications were labeled with a date opened and not expired. A multi-dose vial of Novolog insulin was found expired on the Rainbow unit, and Basaglar and Lantus insulin pens were observed without any date opened on the Reflections unit. Staff interviews confirmed the labeling and discarding requirements were not met.
A resident with multiple health issues indicated that his dentures needed tightening. Despite a care plan noting dental problems and a recommendation for dentures, there were no follow-up visits or documented conversations about continuing the dental plan. The resident had declined dental services in the past but did not refuse a January 2023 dental appointment.
The facility failed to ensure complete and accurate documentation of insulin administration for a resident with type 2 diabetes and cognitive impairment. The MAR showed missing entries for insulin administration on multiple occasions, which the DON confirmed was due to a nurse not signing it out.
A facility failed to implement fall interventions for a resident with Alzheimer's dementia and a history of falls. The resident was observed without the required defined perimeter mattress and floor mat, despite these being specified in the care plan. The DON confirmed the absence of these interventions.
Failure to Update Fall Prevention Interventions After Multiple Resident Falls
Penalty
Summary
A deficiency was identified when the facility failed to update and implement fall prevention interventions for a resident who experienced two falls in one day. The resident, who had diagnoses including dysphagia, weakness, anxiety, osteoarthritis, diabetes, and hypertension, was assessed as cognitively intact but required substantial to maximum assistance with activities of daily living. The care plan, established upon admission, identified the resident as being at risk for falls due to deconditioning and balance problems, with interventions such as maintaining a well-lit and clutter-free environment and keeping personal items within reach. However, after the resident experienced two separate falls in one day—one during therapy and another during a bathroom transfer—there were no updates or revisions made to the care plan to address these incidents. Facility policy required that the care plan be reviewed and updated following any fall. Despite this, the Assistant Director of Nursing Services confirmed that no new interventions were added to the care plan after the falls occurred. This lack of timely care plan revision and implementation of additional fall prevention measures constituted a failure to ensure adequate supervision and accident hazard prevention for the resident.
Incomplete Incontinence Documentation for Dependent Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with significant ADL self-care deficits, specifically regarding incontinence documentation. The resident, who had diagnoses including Alzheimer's, diabetes, weakness, depression, and dysphagia, was assessed as severely impaired in daily decision-making and required total assistance with toileting and other ADLs. The care plan required incontinence care as needed and documentation of any significant decline in function. However, review of the incontinence logs for October and November showed that documentation was only completed once per day on several dates, rather than every two hours as expected. Multiple staff interviews confirmed that the standard practice was to check and change residents every two hours or as needed, but this was not reflected in the documentation for the resident in question. The Director of Nursing Services acknowledged the documentation concern but did not provide additional information. The deficiency was identified through observation, record review, and staff interviews, indicating a failure to maintain clinical records in accordance with accepted professional standards.
Infection Control Lapses in Storage, Wound Care, and PPE Use
Penalty
Summary
Surveyors identified multiple infection control deficiencies within the facility. During an environmental tour, urinals, bedpans, and wash basins were observed improperly stored in shared bathrooms, including being hung from grab bars or placed on the floor, and not contained in plastic bags as required by facility policy. These items were accessible in areas shared by two residents per bathroom. The facility's policy specified that such items should be stored in a resident's bedside cabinet or drawer after being placed in a plastic bag, but this was not followed. Additionally, during wound care for a resident with pressure ulcers, an RN failed to change gloves between treating different wound sites and after providing incontinence care, despite facility policy requiring glove changes between each dressing change and after removing soiled dressings. The RN also placed linen and heel boots on the floor during the procedure. In a separate incident, another RN administered IV medication to a resident on Enhanced Barrier Precautions without donning an isolation gown, as required by both signage and facility policy. These lapses were confirmed through interviews with facility leadership and staff.
Failure to Follow Physician Orders and Monitor Resident Conditions
Penalty
Summary
The facility failed to follow physician orders and care plans for multiple residents, resulting in deficiencies related to medication administration, skin condition monitoring, and implementation of specialist recommendations. For one resident with type 2 diabetes and Parkinson's disease, insulin was administered despite blood glucose levels being below the physician-ordered threshold for holding the medication. Similarly, another resident with hypertension received Metoprolol even when blood pressure readings were below the parameters set by the physician, indicating a failure to hold the medication as ordered. In addition, the facility did not adequately monitor or document skin conditions for residents at risk. One resident on anticoagulant therapy had a large area of purplish discoloration on the hip, but this was not consistently documented in weekly skin reviews as required by facility policy. Another resident with a history of vascular dementia and bowel incontinence experienced frequent episodes of diarrhea, which were reported by CNAs but not documented in nursing notes or addressed with appropriate medication orders. A further resident with a venous stasis ulcer had an open, raw area on the leg that was not treated or care planned for several days, despite visible symptoms and the resident's own report of the condition. The facility also failed to carry out recommendations from specialty physicians for a resident with heart failure and COPD. Orders from a nephrologist to log and fax blood pressures, and from an oncologist to complete specific lab work, were not documented as completed. Additionally, the administration of midodrine for this resident did not consistently follow the ordered blood pressure parameters, with doses given when blood pressure was above the specified threshold and some doses held without documentation of blood pressure readings. These failures were confirmed by interviews with the Director of Nursing, who acknowledged the deficiencies and lack of documentation.
Failure to Complete Food Consumption Logs for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for a resident with a history of weight loss. Record review and interviews revealed that for one resident with multiple diagnoses, including pneumonitis due to inhalation of food and vomit, dementia, Huntington's disease, Parkinson's disease, bipolar disorder, chronic kidney disease, high blood pressure, depression, and dysphagia, there were significant gaps in the documentation of meal intake. The resident had experienced a significant weight loss of more than 5% in 30 days, as noted by a registered dietitian, which was related to a recent hospitalization. Despite the resident's complex medical history and dietary needs, food consumption logs were found to be incomplete for multiple meals across several dates. The Director of Nursing confirmed that these logs were required to be completed after every meal, but review of the CNA task section showed missing documentation for breakfast, lunch, and dinner on numerous occasions. This lack of documentation occurred even though the resident was identified as being at risk due to recent weight loss and ongoing health concerns.
Oxygen Therapy Not Administered at Ordered Flow Rate
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy at the correct flow rate as ordered by the physician. Observations on multiple occasions showed the resident using oxygen via nasal cannula with the concentrator set at 3.5 liters per minute. However, the resident's care plan and current physician's order specified that oxygen should be administered at 2 liters per minute continuously. The resident had diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and dyspnea, and was cognitively intact. The Director of Nursing confirmed that the oxygen should have been set at 2 liters per minute, indicating the resident was not receiving respiratory care as ordered.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to medication storage and labeling. During a medication pass, an RN prepared to administer an IV antibiotic to a resident with a PICC line and left a pre-filled normal saline syringe unsecured on the resident's over bed table after flushing the line. The RN later stated she was unaware that the syringe should not have been left in the resident's room. Additionally, in the Memory Unit medication room, a locked refrigerator contained an emergency drug kit (EDK) box that was found to be expired. The RN present indicated that the pharmacy was responsible for checking the medication room weekly, and the Director of Nursing confirmed that the pharmacy was supposed to check the EDK box during their visits. Further, on the Rainbow Unit, a medication cart was found to contain a multi-dose vial of Lispro Insulin that was past its expiration date. The Director of Nursing acknowledged that the expired insulin should have been discarded. The facility's current medication storage policy requires all drugs and biologicals to be stored in locked compartments or under direct observation during medication passes, and that expired medications should not be present. These observations demonstrate failures to adhere to proper medication storage and labeling protocols.
Failure to Ensure Physician Orders and Assessments for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications had the required physician's orders and assessments in place. In one instance, a resident with heart failure and COPD was observed keeping and self-administering both eye drops and an inhaler at his bedside. Although the resident was cognitively intact and had physician's orders for the medications themselves, there was no order or assessment authorizing self-administration. Staff confirmed that neither the required assessment nor the order for self-administration was present in the resident's record. In another case, a resident with encephalopathy, dementia, and a history of opioid abuse, who was assessed as having severe cognitive impairment, was observed keeping and applying lidocaine patches independently. The resident had a physician's order for the medication but not for self-administration, and no assessment had been completed to determine if self-administration was clinically appropriate. Staff interviews confirmed the absence of the necessary documentation and assessments for both residents, despite facility policy requiring interdisciplinary team determination for safe self-administration.
Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
A dependent resident with diagnoses including kidney failure, ileostomy status, weakness, and a history of falls was observed lying in bed with a covered breakfast tray on her bedside table, unable to eat because she was waiting for wound care. The resident expressed a preference to get out of bed to eat and reported being told she would be assisted after wound care, which had not yet occurred. The resident also reported that her incontinence brief had been put on incorrectly during the night, resulting in her wetting the bed throughout the night and remaining in a soiled bed. Upon observation, a large wet spot was visible on the bed, although the resident's brief had been changed that morning and was dry at the time of observation. Certified nursing assistant (CNA) 1 acknowledged awareness of the soiled bed and stated she had changed the resident's brief but did not change the bed linens, as she intended to do so after the resident was assisted out of bed for wound care. Despite knowing the resident's condition, CNA 1 did not return to the room to provide further assistance and instead attended to another resident. The resident's care plan indicated a need for assistance with dressing, grooming, toileting, and transfers, and the Minimum Data Set assessment documented frequent incontinence and substantial assistance needs for activities of daily living.
Failure to Administer IV Antibiotics and Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to administer prescribed intravenous antibiotics as ordered for three residents and did not ensure wound treatments were completed and documented for one resident. For one resident with a history of prosthetic hip infection and recent surgery, the required six-week course of IV antibiotics was not provided after admission. Documentation showed that only one dose was given, and subsequent doses were missed or discontinued without proper follow-up or clarification with the prescribing physician. There was also a lack of documentation for wound care treatments on several days, and no evidence of communication with the surgeon or infectious disease specialist regarding the antibiotic regimen. Another resident with a chronic non-pressure ulcer and osteomyelitis had multiple missed doses of IV Cefazolin, with no documentation explaining the omissions. The resident's care plan required administration of antibiotics and wound treatment as ordered, but the medication administration record showed several unsigned doses, and the DON was unable to provide reasons for the missed doses. A third resident with osteomyelitis and other comorbidities also had several missed doses of IV Ampicillin-Sulbactam, again with no documentation for the missed administrations. The care plan for this resident included administration of antibiotics per physician orders, but the medication administration record indicated multiple unsigned doses. Interviews with the DON confirmed the lack of documentation or explanation for these missed medications.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident C, after an exit alarm was triggered. Resident C, who was cognitively intact and used a walker for ambulation, was not considered at risk for elopement according to her Elopement Risk Evaluation. On the night of the incident, Resident C exited the facility by entering a door code, which she had learned from her daughter, and was later found to have fallen off the property. She sustained abrasions to her face and finger and was taken to the ER for evaluation and treatment. The incident occurred when the resident exited the building through the ambulance bay door, which she accessed using a code she had overheard from her daughter. The staff did not have a care plan related to wandering for Resident C, as she had no history of wandering or behaviors indicating such a risk. On the night of the incident, a CNA had last seen the resident between 10:00 p.m. and 10:15 p.m., and nothing seemed unusual at that time. However, when the alarm sounded later, the staff assumed it was related to ambulance activity and did not conduct a head count or verify the whereabouts of the residents. The Interim DON confirmed that the staff responded to the alarm but failed to perform a resident head count, which should have been done. The facility's policy on elopements and wandering residents emphasized the importance of door alarms and necessary supervision, but in this case, the staff did not follow through with the required procedures to ensure resident safety. The lack of a systematic approach to monitoring and managing residents at risk for elopement contributed to the incident involving Resident C.
Failure to Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to ensure that all covered individuals were notified annually of their obligation to report reasonable suspicion of crimes against residents. This deficiency was identified in relation to an allegation of sexual abuse involving a resident, referred to as Resident B. During an observation, Resident B, who was not cognitively intact and had impaired cognition and dementia, expressed fear and confusion about a male entering her room at night. The resident had a history of refusing medications and treatments, and during a dialysis session, she reported to a nurse that a male nurse had attempted to force her to take medication and made inappropriate sexual comments. The incident was reported by the dialysis nurse to the Dialysis Facility Administrator, who attempted to notify the long-term care facility's Director of Nursing (DON) but was unable to reach them due to a full voicemail. Despite multiple attempts over several days, the dialysis administrator and social worker could not leave a message or speak directly with the DON. Consequently, the long-term care facility was not informed of the allegation until the surveyor's investigation, and the local police were not notified. The facility's President of Operations confirmed that no annual notifications had been sent to covered individuals regarding their obligation to report suspicious crimes. This lack of communication and failure to notify the appropriate authorities in a timely manner contributed to the deficiency, as the facility did not have a protocol in place to ensure that such allegations were promptly reported and investigated.
Failure to Ensure Continuity of Care Post-Discharge
Penalty
Summary
The facility failed to ensure continuity of care for a resident discharged home with orders for intravenous (IV) antibiotic medications and the care of a peripherally inserted central catheter (PICC) line. The resident, who was cognitively intact, had been admitted with osteomyelitis of the left ankle and foot, among other diagnoses, and required IV antibiotic therapy for six weeks. Upon discharge, the resident was to continue this therapy at home, but the discharge instructions did not include the correct home health agency or pharmacy contact information. The social worker (SW) attempted to arrange for home health services but faced challenges as several agencies would not accept the resident's commercial insurance. Ultimately, the SW reverted to the resident's previous home health agency, which had issues in the past. Although the SW faxed necessary information to the home health and pharmacy agencies, there was no confirmation of receipt, and the SW did not follow up the next day to ensure the resident would receive the required IV antibiotics and PICC line care. The resident contacted the facility after discharge, reporting that he had not received his antibiotics. The facility's administrator and MDS coordinator advised the resident to go to the emergency room for treatment. The resident expressed frustration and questioned whether the facility would cover the ER bill. The lack of follow-up and incorrect discharge instructions contributed to the resident not receiving necessary medical care post-discharge.
Facility Fails to Ensure Palatable and Attractive Food
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. During a Resident Council interview, over half of the residents indicated that the breakfast meal was not good, with complaints about raw and burnt bacon, discolored eggs, and hard sausage patties. One resident compared the eggs to those in the Dr. Seuss book 'Green Eggs and Ham.' The Administrator acknowledged the concerns and mentioned that the facility had a new Dietary Food Manager who would address these issues. Further observations and interviews revealed that residents found the food to be overcooked or undercooked. One resident described the chicken served for lunch as tough and inedible, and another resident's breakfast tray contained an overcooked egg and undercooked bacon. The Dietary Food Manager observed the issues and planned to conduct an inservice on cooking and preparing breakfast food. The Administrator noted that the dietary staff were contracted and suggested it was time for a change.
Failure to Prepare Pureed Diet Correctly
Penalty
Summary
The facility failed to prepare a pureed diet designed to meet the needs of the residents. On 4/17/24 at 11:12 a.m., Cook 1 was observed preparing a pureed cabbage braised recipe. Cook 1 added 10 scoops of cabbage to the mixer and turned on the mix cycle, then added 2 cups of sauerkraut juice, resulting in a watery mixture. Cook 1 added a total of 7 tablespoons of thickener to achieve the appropriate consistency. During an interview, Cook 1 indicated the cabbage was too watery and the recipe would not make 10 servings, requiring her to make more. The Director of Nursing (DON) confirmed that the dietary recipe should have been followed. The provided recipe indicated that water should be added if the product needs thinning.
Failure to Serve Meals on Time
Penalty
Summary
The facility failed to ensure meals were served as scheduled for two meal observations. On 4/16/24, residents were observed seated in the main dining room at 12:20 p.m., but the first tray was not served until 1:15 p.m., causing residents to become impatient. On 4/17/24, the first tray in the main dining room was served at 1:11 p.m., despite the posted meal time being 1:00 p.m. Additionally, a food cart was delayed in reaching the Memory Lane Unit, which was supposed to be served at 12:30 p.m. During a Resident Council interview, residents reported that breakfast was served late on Sunday morning and lunch was late on the day of the interview. They also mentioned that dinner was sometimes served late on bingo night. The Administrator confirmed that the dietary staff was a contracted service and meals should have been served on time.
Failure to Complete Self-Medication Administration Assessment
Penalty
Summary
The facility failed to ensure a self-medication administration assessment was completed for residents with medications at the bedside. Resident 105 was observed with a medication cup containing a small amount of medication solution on her bedside table. Her record indicated she was cognitively intact and had a physician's order for a daily supplement, but there was no self-medication administration assessment or physician's order to self-administer medications. The Director of Nursing (DON) acknowledged that the medication should not have been left at the bedside and had no additional information to provide. Similarly, Resident 2 was observed with a bottle of acetaminophen and tubes of pain-relieving cream on her bedside table. Her record showed she was cognitively intact and had a physician's order for acetaminophen as needed for pain, but there was no self-medication administration assessment or physician's order to self-administer medications or for the topical pain cream. The DON again acknowledged that the medication should not have been left at the bedside and had no additional information to provide.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate ADL assistance to a dependent resident, specifically in relation to nail care and the removal of facial hair. Resident 41, who has diagnoses including senile degeneration, high blood pressure, hallucinations, anxiety, and pain, reported that his nails were long and dirty and had not been cleaned in a while. Observations on multiple occasions confirmed that the resident's nails were long and dirty, and he was unshaven. The resident's care plan indicated an ADL self-care deficit, and the Quarterly MDS assessment noted that he needed partial to moderate assistance with personal hygiene. Despite this, documentation showed that his nails had only been clipped on two occasions earlier in the month, with no record of further nail care or shaving. The Director of Nursing acknowledged that the resident received hospice services and that the CNA was only visiting once a week, but expected nursing staff to ensure the resident's nails were clipped and cleaned and that he was shaved.
Failure to Complete Non-Pressure Skin Treatments and Use TED Hose
Penalty
Summary
The facility failed to ensure non-pressure skin treatments were completed as ordered and TED hose were in use for two residents with edema. Resident 64 was observed with dry, scaly, and red lower legs, and the treatment administration record (TAR) indicated missed applications of Clotrimazole-Betamethasone cream on multiple occasions. The Director of Nursing acknowledged that the treatment should have been completed as ordered, regardless of whether a Qualified Medication Aide (QMA) was on duty. Resident 64's medical history included stroke, heart failure, cellulitis, high blood pressure, and atrial fibrillation, and the resident was not cognitively intact for daily decision-making. Resident 122 was observed multiple times without TED hose, despite a physician's order for daily use to manage edema. The resident's lower extremities were dry, scaly, red, and swollen, with 4+ pitting edema. The TAR indicated that the TED hose were not signed out as being on for several days. Interviews with CNAs revealed a lack of awareness regarding the resident's need for TED hose. The Memory Unit Manager was also unaware of the issue and took immediate action to provide a new set of TED hose and alternate intervention orders. Resident 122's medical history included heart failure, respiratory failure with hypoxia, bipolar disorder, anxiety, cellulitis, and neuropathy, and the resident was moderately impaired for daily decision-making.
Failure to Apply Ankle Braces as Ordered
Penalty
Summary
The facility failed to ensure that ankle braces were applied as ordered for a resident with limited range of motion (ROM). Over several days, the resident was observed multiple times without the prescribed ankle braces while seated in a broda chair. The resident's right and left feet were noted to be leaning on the sides of the foot rest, indicating a lack of proper support. The resident's medical record indicated a diagnosis of spastic cerebral palsy and intellectual disabilities, and a physician's order from June 2023 required the resident to wear bilateral ankle braces for 3-4 hours at a time with skin checks every shift. However, this order was not transcribed onto the Medication or Treatment Administration Records from June 2023 through April 2024, and there was no indication that the ankle braces had been applied in the last 30 days. The resident's care plan did not include any information related to the use of ankle braces, and the Director of Nursing indicated that therapy was supposed to discontinue the order, but there was no documentation to support this. The lack of adherence to the physician's order and the absence of proper documentation and care planning led to the deficiency. The facility's failure to apply the ankle braces as ordered compromised the resident's care and did not support the maintenance or improvement of the resident's ROM and mobility.
Inadequate Supervision in Shower Room Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident in the shower room, resulting in a fall. Resident 34, who has a history of falling and requires partial to moderate assistance with showering, was left alone in the shower room. The resident attempted to stand up to clean herself, but the shower chair's wheels were not locked, causing her to slip and fall. The incident was not witnessed, and the resident indicated that staff had left her alone after initially assisting her. The resident's care plan indicated she needed assistance with transfers during showering, but this was not adhered to during the incident. The resident's fall was documented in a Change of Condition report and a Post Fall Evaluation, both noting that the shower chair's wheels were not locked. An IDT Fall Note confirmed the resident's account of the fall and recommended additional assistance during showers. However, there was no investigation into the resident's claims of being left alone or the unlocked wheels on the shower chair. The Director of Nursing confirmed the resident's account but had no further information to provide.
Failure to Maintain Proper Foley Catheter Care
Penalty
Summary
The facility failed to ensure that foley catheter bags and tubing were kept off the floor for one resident reviewed for catheters. Resident 53 was observed multiple times with the foley bag resting on the ground underneath his wheelchair. These observations occurred on three separate occasions on the same day, indicating a consistent issue with the placement of the catheter bag. The resident's medical history included cerebral palsy, high blood pressure, urine retention, acute kidney disease, and obstructive uropathy. The resident was cognitively intact and dependent on toileting hygiene, as indicated by the Quarterly Minimum Data Set (MDS) assessment dated 1/17/24. The care plan for the resident, dated 2/19/24, specifically included interventions to keep the drainage bag off the floor and below the level of the bladder at all times, which were not followed. Additionally, the resident had a recent urinary tract infection (UTI) and was on antibiotics as per physician's orders dated 4/10/24 and 4/11/24. During an interview, the Director of Nursing (DON) acknowledged the concern but had no additional information to provide.
Failure to Ensure Correct Oxygen Flow Rates
Penalty
Summary
The facility failed to ensure that oxygen was set at the correct flow rate for three residents. Resident 228 was observed multiple times with oxygen set below the prescribed 3 liters per minute, despite physician orders indicating continuous oxygen at this rate. The resident's care plan required oxygen therapy related to chronic respiratory failure, but the observed flow rates did not match the physician's orders. The Director of Nursing confirmed that the oxygen should be administered as ordered by the physician. Resident 37 was observed with varying oxygen flow rates, none of which matched the physician's order of 2 liters per minute. The resident's care plan did not include oxygen use, and there were no orders for oxygen until after the observations were made. Similarly, Resident 116 was observed with inconsistent oxygen flow rates, ranging from 1.5 to 4.5 liters per minute, without corresponding physician orders during the observations. The Director of Nursing acknowledged the discrepancies but had no additional information to provide.
Failure to Properly Label and Discard Medications
Penalty
Summary
The facility failed to ensure medications were labeled with a date opened and not expired. During an observation of the Rainbow unit's medication cart, a multi-dose vial of Novolog insulin was found with an open date that exceeded the 28-day discard period. Additionally, on the Reflections unit, Basaglar and Lantus insulin pens were observed without any date opened. Interviews with the Rainbow Unit Manager and an LPN confirmed that the medications should have been labeled with the date opened and discarded appropriately. The Nurse Consultant also confirmed that the Novolog vial was expired and that the facility's policy required labeling and discarding of multi-use vials within 28 days unless specified otherwise by the manufacturer.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services to a resident who requested dentures. Resident 19, who had diagnoses including high blood pressure, transient cerebral ischemic attack, type 2 diabetes, major depressive disorder, and acute respiratory failure, indicated that his dentures needed to be tightened. An observation confirmed that the resident's upper denture was loose. The resident's care plan, updated in February 2024, noted oral/dental problems, and a dental visit in January 2023 recommended extracting all remaining teeth and making complete upper and lower dentures. However, there were no follow-up visits or documented conversations with the resident regarding the continuation of the dental plan. The Social Service Director noted that the resident had declined dental services in October 2020 and again in October 2023, but the resident did not refuse to be seen by the dentist in January 2023.
Incomplete Documentation of Insulin Administration
Penalty
Summary
The facility failed to ensure clinical records were complete and accurately documented for a resident with type 2 diabetes mellitus and mild cognitive impairment. The resident's Significant Change Minimum Data Set (MDS) assessment indicated severe impairment in daily decision-making and the need for insulin administration. A physician's order specified a sliding scale for Lispro Insulin administration before meals and at bedtime. However, the Medication Administration Record (MAR) showed that the insulin was not signed out as given on multiple occasions in March and April 2024. The Director of Nursing confirmed that a Qualified Medication Aide (QMA) was scheduled on those dates, and the nurse administered the insulin but failed to document it.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure fall interventions were in place as care planned for a resident with a history of falls. Resident B, who has Alzheimer's dementia, osteoporosis, and a history of falls, was observed without the required fall prevention measures. Specifically, the resident's care plan indicated the need for a defined perimeter mattress and a low bed with a mat, but observations on two occasions showed the resident on a standard mattress without a floor mat. The resident had previously fallen on 1/30/24, sustaining minor injuries. The Director of Nursing confirmed the absence of the required interventions during an interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 282 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near La Porte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Laporte Care Center | 0.3 mi | ★★★★★ | 20 | 0 |
| Miller's Health & Rehab By Miller's Merry Manor | 2.7 mi | ★★★★★ | 0 | 0 |
| Aperion Care Arbors Michigan City | 10.4 mi | ★★★★★ | 23 | 1 |
| Life Care Center Of Michigan City | 11 mi | ★★★★★ | 9 | 0 |
| Miller's Merry Manor | 14.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.