Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brickyard Healthcare - Twelfth Street Care Center during CMS and state inspections, most recent first.
Unsafe Milk Temperatures During Breakfast Service: During breakfast service, the kitchen served milk without completing the temp log, and a CDM found a cup of milk at 44 degrees F after trays had already been sent out. In the dining hall, an RN served milk to 12 residents from a gallon container sitting in ice, and the CDM later found that milk at 54 degrees F. The Chef said the milk should have been temp checked before service, and the facility policy required food temps to be recorded before trays were assembled and cold foods kept at or below 41 degrees F.
A resident was observed exposed in bed with the privacy curtain and window curtain open while care was being provided, and the CNA acknowledged both curtains should have been closed. The facility also failed to maintain dignity when a visiting MD made derogatory comments about residents’ weight, tattoos, and an amputee joke, which upset multiple residents including one with dementia and other behavioral health diagnoses.
Medication Storage and Security Lapses: Surveyors found opened and undated polyethylene glycol bottles on a med cart, an unlocked med cart with resident information visible on a laptop, and Gavilyte stored in a pantry refrigerator instead of the locked med room refrigerator. Staff confirmed the opened bottles lacked open dates, the cart should have been locked, and resident meds requiring refrigeration belonged in the med refrigerator.
A resident with cerebrovascular disease and dementia was placed in a WanderGuard after an elopement-related incident, but the resident and POA said they were told it would be temporary and later learned it would stay on unless the resident met added conditions such as med compliance and, at times, treating staff well. Staff accounts conflicted about whether the POA agreed, whether a time frame had been promised, and whether the resident was confused or unsafe, while the chart lacked documentation supporting the claimed behaviors or the POA’s disagreement with the device.
Failure to notify the physician of a resident's low BP was identified for one resident reviewed for meds and treatments. The resident had COPD, acute and chronic respiratory failure with hypoxia, anxiety, depression, opioid dependence, and mild cognitive impairment, and had an order for BP checks every shift. The MAR showed a BP of 79/44, but the record did not show provider notification. Staff interviews and the DON confirmed that low or out-of-range BP should be assessed and reported to the provider, and no nursing note documented the notification.
A resident with CHF, sick sinus syndrome, HTN, and stage 4 CKD received Midodrine 5 mg even when SBP was above the ordered hold parameter of 140 mm/Hg. Observation and EMAR review showed multiple administrations despite elevated BP readings, and the DON confirmed the medication should not have been given when SBP was greater than 140 mm/Hg.
A resident with UTI, type 2 DM, mild cognitive impairment, depression, chronic pain, and wheelchair dependence was supposed to have 2-person transfer assistance, but staff transferred him with only 1 person. After an earlier transfer-related fall, the resident’s legs became weak and he was lowered to the floor, yet the care plan was not updated. Later, the resident and a CNA fell during a wheelchair-to-bed transfer, and the resident hit his head and required sutures in the ER. Interviews showed staff were using the EMR Kardex and shift report for transfer information, while the DON stated the mechanical lift used afterward should have been added to the care plan.
Failure to Monitor Nutritional Status and Weight: The facility failed to monitor the nutritional status of a resident with dementia and adult failure to thrive. The resident had a care plan for a nutritional problem related to chewing issues and prior wt loss, but admission and monthly weights were missing from the chart. The resident was observed leaving meals largely untouched, and the CDM reported repeated wt refusals without documentation of the attempts or MD notification. The facility policy required observations relevant to wt status to be recorded in the medical record.
A resident’s personal refrigerator was observed dirty, with spilled pop on the inside surfaces and floor, grapes without a received-on or use-by date, and an opened jar of nacho cheese without an opened-on or use-by date. The resident said nobody checked the fridge temperature or cleaned it out, and the ED stated the fridge was dirty and opened food should have dates.
Resident Room Square Footage Deficiency: Surveyors observed multiple resident rooms that did not meet required square footage standards, including 22 multi-occupancy rooms in two units and single resident rooms measuring less than 100 square feet per resident. The Administrator confirmed the rooms had variance waivers and did not provide the required space.
A resident with a complex medical history experienced a decline in consciousness and refused medications for several days. The facility failed to notify the physician in a timely manner after the resident was given medication in the incorrect form and continued to refuse medications. The resident was eventually sent to the hospital after the family insisted, highlighting a lapse in following the facility's notification policy.
A facility failed to develop comprehensive care plans for a resident with multiple diagnoses, including type 2 diabetes and congestive heart failure. Despite being on high-risk medications, no care plans were in place to address these conditions. The MDS nurse confirmed the absence of care plans, which should have been established upon admission and when medications were prescribed, as per facility policy.
A facility failed to have Physician Orders for hypoglycemia management for a diabetic resident, leading to a critical low blood glucose event. The resident, with a history of multiple health issues, was found unresponsive and later diagnosed with hypoglycemia at the hospital. Staff interviews revealed a lack of timely assessment and monitoring of the resident's blood sugar levels, despite facility policy requirements.
A resident with Type 2 diabetes had multiple instances of elevated blood glucose levels exceeding 400 mg/dL, but the facility failed to notify the physician as required by the physician's order. Despite the facility's policy on notifying changes, there was no documentation in the nursing progress notes or triage binders indicating that the physician or Nurse Practitioner was informed of these elevated levels.
A resident with hemiplegia and hemiparesis filed a grievance requesting therapy services, which was not addressed in a timely manner by the facility. Despite the resident's request and a grievance filed on 8/5/2024, therapy services were not initiated until a physician's order was made on 9/21/2024. The facility's policy required prompt resolution of grievances, but the delay was attributed to issues with Medicaid funding and staffing for restorative programs.
The facility failed to complete Significant Change MDS assessments within the required 14 days for two residents receiving hospice services. One resident with multiple diagnoses, including COPD and traumatic brain injury, had a delayed assessment after hospice initiation. Another resident with conditions like epilepsy and diabetes also experienced a delay in assessment following hospice service commencement. The Regional MDS Nurse confirmed the assessments should have been completed within the specified timeframe.
The facility failed to maintain grooming for three residents, leading to deficiencies in their ADLs. A resident was observed with long nails and a dark substance underneath, despite requiring assistance. Another resident expressed that staff had not offered to shave him, and observations confirmed increased facial hair growth and long nails. A third resident was found with long fingernails and a dark substance underneath, with no documentation of refusals for care. Interviews with CNAs indicated they provided general ADL care but did not specifically address grooming needs.
A resident with a pressure ulcer on the back of his left upper thigh did not receive adequate treatment and monitoring. Despite reporting the sore weeks prior, the dressing was inconsistently changed, and staff were unaware of the wound care needs. The resident's medical history included chronic venous hypertension and peripheral vascular disease. Facility policies on wound care were not followed, resulting in inadequate management of the pressure ulcer.
A resident with Medicaid was not provided equal access to rehabilitation services at the facility. Despite having a physician's order for therapy, the resident experienced a delay in receiving an evaluation and therapy services due to the facility's policy requiring Administrator approval for Medicaid admissions. The resident, who had significant medical conditions affecting mobility, had requested therapy but did not receive it until later, highlighting a failure to adhere to the facility's policy on specialized rehabilitation services.
Unsafe Milk Temperatures During Breakfast Service
Penalty
Summary
Food was not served at a safe temperature from the main kitchen during breakfast meal service. During observation, the breakfast temperature log had not been completed even though meal trays had already been given to residents. The Certified Dietary Manager tested a cup of milk and found it was 44 degrees Fahrenheit. Four meal trays with cups of milk were then taken from the kitchen window and delivered to residents. The Certified Dietary Manager stated the milk temperature was out of range and should not have been served, while the Chef indicated the milk should have been temperature checked before meal service but the temperature log had been forgotten. In the dining hall, RN 3 served all twelve residents there milk that had been sitting in front of them and stated she had poured the milk from a gallon container sitting in a bowl of ice on the drink cart. RN 3 stated she had nothing to do with temperature checking and that the kitchen was responsible for that task. When the Certified Dietary Manager checked the milk on the drink cart, it was 54 degrees Fahrenheit and was identified as out of range of safe serving temperatures and should not have been served. The facility policy provided by the Executive Director stated that food temperatures are to be recorded daily to ensure food is at proper serving temperatures before trays are assembled, and that potentially hazardous cold foods are to be kept at or below 41 degrees Fahrenheit.
Privacy not maintained and residents subjected to derogatory remarks
Penalty
Summary
The facility failed to protect a resident’s right to privacy during care for Resident 48. During an observation, the resident was lying in bed naked except for a brief while the roommate opened the door all the way, the privacy curtain was open, and the window curtain was partially open. A CNA who was providing care turned toward the door when the surveyor arrived, then turned back to the resident and again toward the door, and the surveyor had to instruct the CNA to pull the privacy curtain. The CNA later stated she had pulled the curtain to remind the roommate to use her walker and acknowledged that both the privacy curtain and window curtain should have been closed; the DON also stated they should have been closed. The facility also failed to maintain dignity when a visiting medical provider made unprofessional and derogatory remarks to residents. Resident 5, who had diagnoses including dementia, epilepsy, bipolar disorder, depression, anxiety, restless leg syndrome, chronic pain, PTSD, borderline personality disorder, and mild intellectual abilities, reported that the provider commented on her weight loss by saying she must have been a “porker” and later said he was “just picking on” her and would stop “assaulting” her. A social services note documented that Resident 5 was tearful after a doctor visit, and the provider’s written statement described making comments about residents’ weight, tattoos, and a tasteless joke about an amputee. Resident 40, who had diagnoses including diabetes mellitus, morbid obesity, COPD, depression, anxiety, venous insufficiency, and hypertension, reported that the same visiting MD asked whether she had any naked tattoos and repeated a joke about another resident, which left her feeling “a little creeped out.” Resident 27, who had diagnoses including diabetes mellitus, neuropathy, hypertension, bullous pemphigoid, and anxiety, reported hearing the provider make inappropriate remarks about overweight residents, including the word “porker,” and said it made her angry. Another resident witness stated the provider referred to “all of the fat people” at the facility and that Resident 27 became very upset.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure medications were stored appropriately, including opened and undated medications, a medication cart that was left unlocked, and medications stored in the wrong refrigerator. On the 200 hall medication cart, surveyors observed 5 opened and undated bottles of polyethylene glycol. During interview, QMA 15 stated the opened bottles should have had open dates. On the 100 hall, the medication cart was observed unlocked with a laptop open and resident information visible to passersby. RN 5 stated she had left to attend to a resident’s needs and should have locked the cart and closed the laptop. On the 200 hall pantry, surveyors observed a bottle of Gavilyte in the refrigerator door of the pantry refrigerator. The Certified Dietary Manager stated resident medications should not be stored in pantry refrigerators. LPN 3 stated resident medications that require refrigeration should be kept in the medication refrigerator in the locked medication room. The Administrator provided the facility’s Medication Storage policy, which stated medications are to be stored with proper sanitation, temperature, light, ventilation, moisture control, segregation, and security, and that refrigerator temperatures are to be recorded daily.
Failure to Inform Resident and POA About WanderGuard Use and Removal Conditions
Penalty
Summary
The facility failed to respect the right of a resident and his POA to be informed in advance of the risks, benefits, and alternatives related to a WanderGuard and to choose the option they preferred. The resident had diagnoses including cerebral infarction, vascular dementia, major depressive disorder, hypertension, chronic kidney disease, anemia, and COPD. Multiple staff members described him as generally alert, oriented, slow to respond, and able to make his needs known, with several stating they had not observed confusion except during illness or after the incident that led to the WanderGuard. After the resident left the facility on an electric scooter and staff attempted to stop him, the facility placed a WanderGuard on his ankle. The resident and his POA stated they were told the device would be temporary and removed after two weeks, but it remained in place beyond that time. The resident reported that he had not understood what was happening during the incident because he had always been permitted to leave the facility and go to the park, and he said his main concern was having the monitor removed. The POA stated she had not agreed to the WanderGuard and had only accepted it because she was told it was temporary. During care plan meetings and follow-up discussions, facility staff documented that the WanderGuard would remain until the resident passed an assessment and was compliant with medications. Staff interviews conflicted on whether the POA agreed with the device, whether a time frame had been promised, and whether additional conditions such as medication compliance and treating staff well were required for removal. The record included care plan minutes and notes stating the WanderGuard would stay on for safety, but the resident’s record lacked documentation showing the POA was not agreeable to the device, and it lacked notes or behavior monitoring supporting claims that the resident had been physically or verbally aggressive, impulsive, or attempting to leave the facility since the WanderGuard was placed.
Failure to Notify Physician of Low Blood Pressure
Penalty
Summary
The facility failed to notify the physician of a resident's low blood pressure for 1 of 5 residents reviewed for medications and treatments. Resident 39 had diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, anxiety, depression, opioid dependence, and mild cognitive impairment. A quarterly MDS assessment indicated the resident was cognitively intact and had received an antidepressant, an anticoagulant, an opioid, and a diuretic. A physician's order required blood pressure checks every shift to monitor for blood pressure drops, and the September 2025 MAR showed a blood pressure of 79/44 on the night shift of 9/1/2025. The resident's clinical record did not show provider notification of the low blood pressure reading. During interviews, QMA 6 stated that low blood pressure would be reported to the nurse in charge and documented in the EMR, RN 5 stated she would assess the resident, review the medication list, and notify the provider if the blood pressure was outside the resident's normal range, and the DON stated the physician should be notified when a resident's blood pressure was out of normal range. The DON confirmed there were no nursing notes documenting provider notification, and the facility policy on Notification of Changes stated the facility must consult with the resident's physician when there is a significant change in condition, including deterioration in health or clinical complications.
Failure to Hold Midodrine When Blood Pressure Exceeded Ordered Parameters
Penalty
Summary
The facility failed to follow a physician’s order for Midodrine Hydrochloride 5 mg for Resident 9, who had diagnoses including acute on chronic systolic heart failure, sick sinus syndrome, hypertension, and stage 4 chronic kidney disease. The order, dated 6/13/2025, directed that the medication be given by mouth three times per day but held if the resident’s systolic blood pressure was greater than 140 mm/Hg. During observation on 9/10/2025 at 9:33 A.M., Resident 9 received Midodrine Hydrochloride 5 mg by mouth when the blood pressure was 142/58 mm/Hg. Record review showed multiple additional instances in which the medication was administered despite systolic blood pressure readings above the ordered parameter, including readings of 141, 143, 146, 169, 151, 167, 144, 141, 144, 169, 167, 160, 141, 141, 144, 146, 160, 155, 160, 146, 165, 144, 144, 149, 148, 144, 158, 158, 155, and 142 mm/Hg across various shifts. A 9/10/2025 physician’s order also directed monitoring for adverse reactions related to Midodrine Hydrochloride and blood pressure checks every two hours until 11:59 P.M. On 9/12/2025, the DON stated that Resident 9 should not have received Midodrine Hydrochloride when the systolic blood pressure was greater than 140 mm/Hg.
Unsafe Resident Transfer Resulted in Fall and Head Injury
Penalty
Summary
The facility failed to safely transfer a resident, resulting in a fall for 1 of 1 resident reviewed for falls. The resident had diagnoses including UTI, type 2 DM, mild cognitive impairment, major depressive disorder, and chronic pain disorder. The admission MDS indicated intact cognition, functional limitations of one upper extremity, use of a wheelchair, substantial to maximal assist for transfers, and a history of one prior fall before reentry to the facility. The care plan problem for ADL deficit, initiated on 7/28/2025, was revised on 9/5/2025 to require assist of 2 staff for transfers. The record showed that on 8/26/2025 the resident was transferred with assist of one staff, his legs became weak, and he was lowered to the floor; the note stated he would be a 2-person transfer thereafter, but no care plan updates were found. On 9/4/2025, the resident and a CNA fell during a transfer from the wheelchair to bed when the CNA transferred him alone; the resident hit his head and was sent to the ER, where sutures were required above the right eyebrow. Interviews showed staff relied on the EMR Kardex and shift report for transfer status, but the CNA who performed the transfer stated the resident was a 1-person transfer at the time. The DON stated the mechanical lift used later was a nursing judgment and should have been added to individualize the care plan, and therapy and clinical leadership noted the resident’s transfer status had been discussed after the earlier fall but was not entered into the record.
Failure to Monitor Nutritional Status and Weight
Penalty
Summary
The facility failed to monitor the nutritional status of one resident reviewed for nutrition. The resident had diagnoses including unspecified dementia and adult failure to thrive. An admission MDS dated 8/28/2025 indicated the resident was cognitively intact, needed set up/clean up assistance for eating, and had no swallowing or chewing issues. However, the care plan initiated on 8/21/2025 identified a nutritional problem related to a self-reported chewing issue with prior unspecified weight loss, and staff were to monitor for signs or symptoms of dysphagia and serve the diet as ordered. Record review showed that admission and September weights could not be found in the chart. A dietician note documented a pre-admission weight of 117 pounds. During observation, the resident left about 50% of lunch untouched and later had breakfast almost completely untouched, stating she hated the food and was not hungry. The CDM stated the resident refused to be weighed and that several attempts had been made, but documentation of the attempts, the refusals, and physician notification were not in the chart. The Regional Director of Clinical Operations stated the scale was in the shower room and the resident would not be weighed if she did not go into that room, and that the refusals should have been documented. The facility policy titled Weight Monitoring stated that observations pertinent to the resident's weight status should be recorded in the medical record as appropriate.
Dirty Personal Refrigerator and Unlabeled Opened Food
Penalty
Summary
The facility failed to maintain the cleanliness of one resident’s personal refrigerator. During observation, the refrigerator contained pop splattered and spilled on the inside sides, inside door, and shelf. A container of grapes was removed and pop spilled onto the floor because pop had accumulated on the lid, and an opened jar of nacho cheese was not labeled with an opened-on date or use-by date. The resident stated that nobody checked the refrigerator temperature or cleaned it out and believed his sister had been cleaning it in the past. The Executive Director stated that the refrigerator was dirty and should not have been, and that all opened food should have an opened-on or use-by date. The facility policy provided by the Executive Director stated that staff, resident, or family shall clean the refrigerator and that leftovers shall be dated upon receipt and discarded within three days.
Resident Room Square Footage Deficiency
Penalty
Summary
The facility failed to provide the required room square footage in multiple resident rooms during an environmental tour on 9/11/2025. Surveyors observed that 22 multiple-occupancy resident rooms in Units 100 and 200 did not meet the required space standards, including rooms listed as 3-bed certified SNF/NF rooms that measured between 70.5 and 72 square feet per resident, and other multiple-occupancy rooms that measured about 107.55 to 108.8 square feet per resident. The report also identified single resident rooms that did not provide the required 100 square feet per resident, including rooms measured at 91.6 square feet per resident. During the tour, the rooms identified included rooms 100, 101, 103, 104, 108, 109, 110, 111, 112, 114, 116, 118, 204, 205, 206, 207, 211, 213, 215, and 226, along with additional rooms described in the findings. In an interview on 9/11/2025 at 1:40 P.M., the Administrator confirmed these were the rooms with room variance waivers and acknowledged that they did not provide the required square footage.
Failure to Notify Physician of Medication Errors and Resident Decline
Penalty
Summary
The facility failed to ensure timely notification of a physician when a resident, identified as Resident B, was given medication in the incorrect form, refused all medications for six consecutive medication passes, and experienced a decline in level of consciousness. Resident B had a complex medical history including stroke, seizures, heart failure, hypertension, diabetes, and dementia. The resident's Medication Administration Record (MAR) indicated that from March 1 to March 3, 2025, the resident did not receive any prescribed medications due to refusals and incorrect administration. On March 2, 2025, the resident's medications were not administered due to charted nausea and vomiting, although it was later clarified that the resident had refused the medications. On March 3, 2025, the resident continued to refuse medications and meals, and was noted to be very difficult to arouse. Despite these significant changes in condition, there was no documentation of physician notification until the resident's representative requested medical attention. The resident was eventually sent to the hospital for evaluation and treatment after the family insisted. Interviews with facility staff revealed that the resident's Depakote ER was crushed, which is against proper administration guidelines, and that the resident's lack of responsiveness and medication refusals were not promptly communicated to the physician. The facility's policy on notification of changes was not followed, as significant changes in the resident's condition were not reported in a timely manner, leading to a delay in appropriate medical intervention.
Lack of Comprehensive Care Plans for Resident with Multiple Diagnoses
Penalty
Summary
The facility failed to ensure comprehensive care plans were in place for a resident with multiple medical conditions, including type 2 diabetes, seizures, bipolar disorder, congestive heart failure, and anxiety. Upon review of Resident B's medical records, it was found that despite being admitted in September 2024 with these diagnoses, there were no care plans addressing these conditions or the medications prescribed for them. The resident was on several high-risk medications, including antipsychotics, antidepressants, and a diuretic, yet the necessary care plans to manage these conditions and medications were absent. During an interview, the MDS nurse confirmed that Resident B did not have care plans for the listed diagnoses and medications, which should have been established upon admission and when the medications were prescribed. The facility's policy mandates the development and implementation of comprehensive, person-centered care plans that include measurable objectives and timeframes to meet the resident's needs. However, this policy was not adhered to in the case of Resident B, leading to the deficiency cited in the report.
Failure to Manage Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to ensure that Physician Orders were in place for the treatment of low blood glucose and did not assess hypoglycemia in a timely manner for Resident B, who was one of three residents reviewed for diabetic treatment. Resident B had a history of stroke, seizures, heart failure, hypertension, diabetes, hyperlipidemia, dementia, and chronic obstructive pulmonary disease. Despite being severely cognitively impaired, Resident B was sometimes able to communicate his needs. The resident was on multiple medications for type 2 diabetes, but there were no orders for hypoglycemia management or a plan of care addressing the diabetes diagnosis. On a specific day, Resident B was reported to be very difficult to arouse and had not taken his medications due to lack of alertness. The resident's family requested hospital evaluation due to his unresponsiveness. The Emergency Department noted a critically low blood glucose level of 18 mm/dl, indicating hypoglycemia and altered mental status. Interviews with facility staff revealed that the resident's condition had been declining, and although vital signs were checked, blood sugar levels were not monitored. The facility's policy required glucose monitoring and treatment orders for residents at risk of hypoglycemia, which were not in place for Resident B.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of significantly elevated blood glucose levels for a resident diagnosed with Type 2 diabetes. The physician's order required notification if the resident's blood glucose levels were below 60 mg/dL or above 400 mg/dL. However, the facility did not document any notification to the physician when the resident's blood glucose levels exceeded 400 mg/dL on multiple occasions. Specifically, the resident's blood glucose levels were recorded as 420 mg/dL, 433 mg/dL, 450 mg/dL, and 416 mg/dL on different dates, yet there was no evidence that the physician was informed of these elevated levels. Interviews with facility staff, including the Administrator, Director of Nursing (DON), and RN 5, revealed that the elevated blood glucose levels should have been documented in a nursing progress note or the triage book. However, a review of the triage binders on both the resident's previous and current halls showed no notes indicating that the Nurse Practitioner (NP) was contacted regarding the resident's out-of-range blood glucose levels. The facility's policy on Notification of Changes, which was undated, stated that the facility should promptly inform the resident, consult the physician, and notify the resident's representative when there is a change requiring notification. Despite this policy, the required notifications were not made in this case.
Delayed Response to Resident's Grievance for Therapy Services
Penalty
Summary
The facility failed to respond to a resident's grievance in a timely manner, specifically regarding the request for therapy services. Resident L, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, expressed during an interview that he had not received the therapy he sought upon admission. He had filed a grievance on 8/5/2024, expressing concerns about the wait time for colostomy care and the need for therapy. The grievance form indicated a resolution on the same day, but the resident did not receive therapy services until a physician's order was made on 9/21/2024. The Director of Rehab noted that she could not evaluate new admissions with Medicaid funding without the Administrator's permission, and the Administrator confirmed that the facility did not offer a restorative program due to staffing and reimbursement issues. Despite the resident's request and the grievance filed, the Administrator did not provide a satisfactory explanation for the delay in addressing the grievance. The facility's policy required prompt efforts to resolve grievances, but the resolution for Resident L's request for therapy was delayed significantly.
Failure to Timely Complete Significant Change MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment in a timely manner for two residents who were receiving hospice services. Resident 16, with diagnoses including chronic obstructive pulmonary disease, traumatic brain injury, depression, bipolar disorder, and anxiety disorder, had a hospice contract initiated on March 28, 2024. However, the Significant Change MDS assessment was not completed until June 19, 2024, which was not within the required 14 days after the initiation of hospice services. The Regional MDS Nurse confirmed that the assessment should have been completed within 14 days of the hospice services initiation. Similarly, Resident 28, who had diagnoses including epilepsy, type 2 diabetes mellitus, Crohn's disease, dysphagia, spinal stenosis, and benign prostatic hyperplasia, had a hospice agreement dated August 2, 2024, with hospice services starting on August 12, 2024. The facility failed to complete a Significant Change MDS assessment within 14 days of the hospice order. The Regional MDS Nurse acknowledged that the assessment should have been completed within the specified timeframe. The facility does not have a specific policy for MDS assessments but follows the Resident Assessment Instrument (RAI) manual.
Deficiency in Grooming and ADL Care for Residents
Penalty
Summary
The facility failed to maintain proper grooming for three residents, leading to deficiencies in their activities of daily living (ADLs). Resident 15 was observed multiple times with long nails and a dark substance underneath them. Despite having a care plan indicating a self-care deficit and requiring assistance, there was no documentation of any refusals for nail care. Interviews with CNAs revealed that while they provided various aspects of ADL care, there was no mention of addressing nail care specifically. Resident L expressed that staff had not offered to shave him, despite his preference for a closer shave with a razor. His care plan required assistance with personal hygiene, including shaving, due to limited movement in his left arm. Observations confirmed increased facial hair growth and long nails with a brown substance underneath, with no documentation of refusals for care. Interviews with CNAs indicated they provided general ADL care but did not specifically address shaving or nail care. Resident 21 was also found with long fingernails and a dark substance underneath them. His care plan required staff assistance for grooming, but there was no documentation of refusals for hygiene or grooming assistance. Interviews with CNAs indicated they provided comprehensive personal care, including nail care, but there was no evidence of this being done for Resident 21. The facility's policy on ADLs included grooming, but the observations and interviews suggest a lack of adherence to this policy.
Inadequate Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide adequate treatment and monitoring for a pressure ulcer for Resident 37, who had a sore on the back of his left upper thigh. The resident reported the sore to the nursing staff 3-4 weeks prior, and it was attributed to his wheelchair cushion. Despite receiving a new cushion, the resident indicated that the dressing on the sore was only replaced every couple of days upon his request. Observations revealed that the dressing was undated, uninitialed, and showed visible drainage, indicating inadequate wound care management. The resident's medical history included chronic venous hypertension with ulcer of bilateral lower extremity and peripheral vascular disease. A significant MDS assessment indicated normal cognition. Progress notes from the wound care office detailed the wound's measurements and treatment plan, which included cleansing with soap and water, daily dressing changes with Medihoney Gel, and offloading with a cushion for pressure relief. However, interviews with nursing staff revealed a lack of awareness and documentation regarding the resident's wound care needs, with some staff indicating no wounds were being monitored or treated. The facility's policies on notification of changes, skin assessment, and clean dressing change were not adhered to, as evidenced by the lack of consistent documentation and communication regarding the resident's wound care. The DON indicated that wounds should be measured weekly, and new wounds should be documented, with treatment orders obtained. However, the resident's wound care was inconsistent, and staff failed to follow the established protocols, leading to inadequate treatment and monitoring of the pressure ulcer.
Failure to Provide Equal Access to Rehab Services for Medicaid Resident
Penalty
Summary
The facility failed to provide equal access to rehabilitation services for a resident with Medicaid as a payer source. Resident L, who had been admitted to the facility with the expectation of receiving therapy, reported that he had not received any range of motion exercises or therapy since his admission. Despite having a physician's order for physical therapy, the resident experienced a delay in receiving an evaluation and therapy services. The Director of Rehab indicated that she was unable to evaluate new admissions with Medicaid without the Administrator's permission, which contributed to the delay in Resident L's therapy evaluation and services. Resident L had significant medical conditions, including hemiplegia and hemiparesis following a cerebral infarction, which affected his left side. His admission Minimum Data Set assessment indicated he required assistance with personal hygiene, bathing, and transfers, and had impaired range of motion on his left side. A baseline care plan outlined the need for physical and occupational therapy to improve his functional status and minimize decline. However, the therapy services were not initiated until after the Administrator approved them, despite the resident's requests and the Director of Rehab's belief that he would benefit from therapy. The Administrator acknowledged that the facility did not offer a restorative program and that they did not receive reimbursement for therapy services for residents with Medicaid. This financial consideration appeared to influence the delay in providing therapy services to Resident L. The Administrator confirmed that Resident L had requested therapy and that his request was addressed in a written grievance. The facility's policy on specialized rehabilitation services indicated that such services are considered a facility service and should not be charged to Medicaid recipients, yet the delay in providing these services suggests a failure to adhere to this policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mishawaka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trailpoint Village | 2.5 mi | ★★★★★ | 19 | 0 |
| Brickyard Healthcare - Fountainview Care Center | 3.5 mi | ★★★★★ | 3 | 0 |
| Cardinal Nursing And Rehabilitation Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Creekside Village | 4 mi | ★★★★★ | 14 | 0 |
| Belltower Health & Rehabilitation Center | 4.4 mi | ★★★★★ | 1 | 0 |
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