Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brickyard Healthcare - Woodbridge Care Center during CMS and state inspections, most recent first.
Incomplete care plans for fall risk, catheter management, and activities. A resident with dementia and hemiplegia had a fall-risk care plan that called for a "Call Don't Fall" sign, but the sign was not in the room and was later found on the floor behind furniture. Another resident with a suprapubic catheter had the catheter bag observed across the leg and later on a leg peddle while in the activities room, and the chart lacked an activities care plan despite the resident's needs and the Activities Director's stated process for care planning.
Infection control practices were not followed during glucometer cleaning and catheter care. An LPN/QMA cleaned multi-resident use glucometers with an alcohol pad after Accu-Chek testing instead of following the stated disinfection process, and during catheter care for a resident with a suprapubic catheter, staff performed brief hand hygiene and handled linens and supplies while using gown and gloves.
A resident with end stage renal disease did not receive consistent monitoring of their dialysis access site as ordered, with several shifts lacking documentation of required assessments. The resident also refused or left dialysis treatments early on multiple occasions, but there was no evidence that the physician was notified of these events, contrary to facility policy.
A resident with severe cognitive impairment and a history of cerebral infarction had their Norco medication and count sheet go missing from the medication cart. The issue was discovered during a hospice visit when a nurse checked the medication supply. Despite the missing medication, the resident showed no signs of pain or distress. The incident was reported, and all nurses were drug tested with no concerns identified.
The facility failed to provide timely showers for four dependent residents, as documented in the report. A resident with cerebral palsy reported not receiving showers on scheduled days, confirmed by facility records. Another resident with end-stage renal disease and dementia missed several scheduled showers, as did a resident with severe cognitive impairment. A cognitively intact resident also reported not receiving showers for two weeks. The facility did not use shower sheets, and refusals were documented in the Point of Care Tasks.
The facility failed to maintain a sanitary environment, with persistent urine odors observed in various areas over multiple days. Despite a policy to minimize odors, the issue was not effectively addressed, as noted by an LPN and through multiple observations.
A resident with quadriplegia and other complex medical conditions was transported in an improperly fitted manual wheelchair because their personal electric wheelchair could not fit in the facility's mobility van. The manual wheelchair did not support the resident's trunk, contrary to a prior assessment indicating that only a power wheelchair met the resident's mobility needs. The facility's policy required therapist evaluations, but this was not adequately followed, resulting in a deficiency in accommodating the resident's mobility needs.
A resident with pressure ulcers refused wound treatments multiple times, and the facility failed to notify the physician of these refusals or the resident's treatment timing preferences. Additionally, MRI results indicating osteomyelitis were not promptly communicated to the physician, contributing to the deficiency.
A resident, fully dependent on staff due to quadriplegia, was allegedly slapped by an employee during evening care. The employee was suspended and later resigned without participating in the investigation. The facility's policy requires immediate reporting of abuse, but there was a lack of communication and clarity in handling the incident.
The facility failed to provide proper documentation during the transfer of two residents to the hospital. One resident with complex medical needs was transferred without documents on one occasion and with illegible documents on another. Another resident with end-stage renal disease was transferred without the necessary paperwork, including transfer orders and bed hold information.
A facility failed to accurately complete the MDS assessment for a resident with cerebral palsy and flaccid neuropathic bladder. The Quarterly MDS inaccurately documented the resident's catheter and colostomy status, which was later acknowledged by the MDS nurse as needing correction. This discrepancy highlights a lapse in following the facility's policy on accurate resident assessments.
The facility failed to implement physician orders and develop comprehensive care plans for three residents regarding unnecessary medications. One resident had incomplete documentation for monitoring side effects and interventions related to their medications. Another resident had missed doses and lacked documentation for monitoring side effects of various medications. A third resident's record lacked an order to monitor for side effects of an antiplatelet medication and did not have a care plan addressing its use.
A resident received an incorrect insulin dose due to improper priming of a Humalog Insulin Kwikpen by an RN. The RN administered 6 units instead of the required 4 units, misunderstanding the priming process. An LPN incorrectly stated that priming was unnecessary, contrary to the user manual and facility policy, which both require priming to ensure accurate dosing.
The facility failed to provide restorative services as outlined in the care plans for three residents, leading to a deficiency in maintaining or improving their range of motion (ROM). A resident with dementia had a care plan for AROM exercises, but records showed numerous dates in 2024 where no exercises were provided. Another resident with Parkinson's disease and dementia also missed several scheduled AROM sessions. A third resident with end-stage renal disease and dementia had a similar lapse in care. The Occupational Therapist noted that nursing staff were responsible for these therapies, but the facility's policy required the restorative nurse to ensure program implementation.
A resident with a history of falls and cognitive intactness experienced multiple falls due to inadequate care plan updates and incomplete documentation. Despite known risks and facility policies requiring care plan revisions after falls, the facility failed to consistently update the care plan with new interventions, contributing to ongoing fall risks.
A facility failed to follow physician orders and care plans for a resident requiring hemodialysis. Despite orders to avoid taking blood pressure from the resident's arm with a fistula, staff repeatedly did so. Additionally, the facility did not consistently record the resident's weight after dialysis sessions, as required. These deficiencies were confirmed through staff interviews and record reviews.
The facility failed to serve food at appropriate temperatures, as a meal tray test showed non-compliance with temperature standards. Interviews with residents revealed dissatisfaction with food temperatures, and the Dietary Manager confirmed the expected standards. The facility's policy requires hot foods to be at least 135°F and cold foods at or below 41°F.
The facility failed to ensure safe storage of foods for a resident, as their refrigerator had blank temperature logs with no recorded temperatures. The resident, who was cognitively intact but fully dependent on staff, had a refrigerator that was not monitored as per facility policy. An LPN indicated that staff were supposed to record temperatures during rounds, but this was not done.
The facility failed to maintain accurate documentation and medication administration for residents. A resident received a duplicate sertraline order due to a transcription error, while another resident's therapeutic leaves were not properly documented or authorized. Additionally, a resident's skin assessments were inconsistent with treatment orders, indicating incomplete documentation.
The facility failed to clean multi-resident use glucometers according to the manufacturer's instructions. A nurse was observed cleaning a glucometer for only 2 seconds, while the correct procedure required a 30-second contact time with a bleach wipe. Conflicting information from staff and the infection preventionist contributed to the deficiency.
Incomplete care plans for fall risk, catheter management, and activities
Penalty
Summary
The facility failed to ensure care plans were developed and implemented for a resident with fall risk and for a resident with a suprapubic catheter, and it also lacked an activities care plan for the resident with the catheter. Resident 5 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and dementia. The most recent quarterly MDS indicated severe cognitive impairment, dependence on staff for transfers, and no falls since the prior assessment. Although the fall risk care plan included an intervention to place a "Call Don't Fall" sign in the room, the sign was not observed in the room on 7/24/25, and RN 3 stated she was not sure whether that intervention was in the plan of care. Regional Support 9 later found the sign on the floor behind furniture and stated the tape used was not sticky enough to hold it. Resident 3 had diagnoses including neurogenic bladder and diabetes mellitus type 2, with a suprapubic catheter and mild cognitive impairment on the most recent quarterly MDS. The resident required setup assistance for eating and was dependent on staff for hygiene, dressing, and mobility. During observation, the catheter bag was seen laying across the resident's leg while seated in a wheelchair in the activities room, and later it was observed sitting on the edge of the extended left leg peddle while the resident remained in the activities room. The clinical record included a catheter care plan with an intervention to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, but it lacked a care plan related to activities. The Activities Director stated each resident should have an activities care plan upon admission, significant change, quarterly, and annually.
Infection Control Lapses During Glucometer Cleaning and Catheter Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during catheter care and during the cleaning of multi-resident use glucometers. During two random observations, QMA 5 cleaned a multi-resident use glucometer with an alcohol preparation pad after performing Accu-Chek testing on Resident 17 and Resident 31. The Regional Director later stated that glucometers were to be cleaned for 1 minute using cleaning wipes per manufacturer instructions, and the facility used Micro Kill 1 Germicidal Wipes. During an observed catheter care procedure for Resident 47, who was cognitively intact and dependent on staff for toileting, bathing, and transfers, LPN 17 and QMA 15 entered the room with gown and gloves, positioned the resident, and removed her brief. QMA 15 removed gloves and washed hands for 12 seconds, then put on new gloves and cleaned around the resident’s suprapubic catheter and dried in the same motions. After bagging dirty linens, emptying wash basins, and removing gowns and gloves, QMA 15 washed hands for 7 seconds and exited the room. LPN 15 then used hand sanitizer for three seconds before carrying dirty linens away. Resident 47 had diagnoses including incontinence, a history of UTI related to an indwelling catheter, and orders for Foley catheter care every shift, Enhanced Barrier Precautions, and contact isolation.
Failure to Provide Safe and Appropriate Dialysis Care and Physician Notification
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who was dependent on renal dialysis. The resident had physician orders for dialysis treatments three times a week and required daily and nightly monitoring of the left dialysis permacath site. However, documentation showed that the required monitoring of the dialysis access site was not completed on several shifts, as indicated by missing entries in the Treatment Administration Record (TAR) for specific dates. The resident's care plan also required routine observation of the permacath, which was not consistently documented. Additionally, the resident refused or left dialysis treatments early on multiple occasions, as recorded in the dialysis/observation communication forms. Despite these refusals and early terminations, there was no documentation in the resident's progress notes that the physician was notified of these events, which was required by facility policy. Interviews with staff confirmed that physician notification and documentation should occur when a resident refuses or leaves dialysis early, but this was not done in these instances.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's narcotic medication, specifically Norco, for a resident with severe cognitive impairment and a history of cerebral infarction, diabetes, and aphasia. During a hospice visit, it was discovered that the resident's Norco medication and the associated count sheet were missing from the medication cart. This incident was identified when a hospice nurse inquired about the need for a refill, prompting a facility nurse to check the medication supply. The facility's records indicated that the resident was at risk for pain due to their medical history, and interventions included administering pain medications as ordered. Despite the missing medication, the resident did not display signs of pain or psychosocial distress during monitoring. The incident was reported to the appropriate authorities, and all nurses were drug tested with no concerns identified. A full reconciliation of all narcotics in the building was completed, and no discrepancies were found.
Failure to Provide Timely Showers for Dependent Residents
Penalty
Summary
The facility failed to provide timely showers for four dependent residents, as observed and documented in the report. Resident 4, who is cognitively intact but dependent on staff for hygiene due to cerebral palsy, reported not receiving showers on scheduled days. The facility's records confirmed missed showers on several occasions from February to June. Despite interventions in place for uncooperative behavior, such as offering bed baths, the resident indicated that showers were not provided as scheduled. Resident 13, who requires moderate assistance for bathing due to end-stage renal disease and dementia, also missed several scheduled showers. The facility's documentation system showed that showers were not given or refused on multiple dates. Similarly, Resident 2, who is severely cognitively impaired and dependent on staff for bathing, missed numerous scheduled showers. Resident 6, who is cognitively intact and dependent on staff for bathing, reported not receiving showers for two weeks, with records indicating multiple missed showers. The facility did not use shower sheets, and refusals were documented in the Point of Care Tasks.
Facility Fails to Maintain Sanitary Environment Due to Persistent Urine Odors
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, staff, and the public, as evidenced by persistent urine odors in various areas of the facility over multiple days. Observations were made on five out of six days, where the smell of urine was detected in the 100 Unit Hallway, 200 Unit Hallway, Basement Hallway, conference rooms, common areas, and stairwells. These observations were made at different times of the day, indicating a consistent issue with odor management and sanitation. During an interview, an LPN acknowledged that the facility should be free of smells, highlighting awareness of the issue among staff. The facility's policy on maintaining a safe and homelike environment was reviewed, which stated that housekeeping and maintenance services should be provided to minimize odors by promptly disposing of soiled linens and reporting lingering odors to the Housekeeping Department. Despite this policy, the facility did not effectively address the odor issue, leading to the deficiency noted in the report.
Improper Wheelchair Accommodation for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's mobility needs by transporting the resident in an improperly fitted manual wheelchair. The resident, who was observed sitting in the manual wheelchair in the hallway, expressed a desire to get out of the wheelchair and go to bed. The manual wheelchair was not the resident's personal wheelchair but was used by staff for transportation because the resident's personal electric wheelchair could not fit in the facility's mobility van. The resident's clinical record indicated multiple diagnoses, including quadriplegia, post-traumatic seizures, COPD, stage four pressure ulcers, and muscle/joint contracture, and the resident was fully dependent on staff for various activities of daily living. An occupational therapist was not aware until recently that the resident's trunk was not being supported in the manual wheelchair used for transportation. A Functional Mobility and Wheelchair Assessment indicated that manual wheelchair use was contraindicated for the resident due to their diagnoses, and a power wheelchair was necessary for safe and independent mobility. The facility's policy required a licensed therapist to perform evaluations upon physician referral, but it appears this was not adequately followed, leading to the deficiency in accommodating the resident's mobility needs.
Failure to Notify Physician of Treatment Refusals and MRI Results
Penalty
Summary
The facility failed to notify a resident's physician about the refusal of wound treatments for a resident with multiple pressure ulcers. The resident, who was cognitively intact and fully dependent on staff for daily activities, had several physician orders for wound care that were not followed due to the resident's refusal during sleep hours. Despite the resident's refusals being documented multiple times over a period of weeks, the physician was not informed of these refusals or the resident's preference for treatment timing. Additionally, the facility did not communicate the results of an MRI indicating osteomyelitis to the resident's physician in a timely manner. The facility's policy on promoting resident self-determination was provided, but a specific policy on physician notification was not available. This lack of communication and adherence to treatment protocols contributed to the deficiency identified by the surveyors.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. The incident involved a resident who was cognitively intact and fully dependent on staff for daily activities due to quadriplegia and muscle/joint contracture. During evening care, an employee allegedly made physical contact with the resident's head. The employee was suspended pending investigation but chose not to participate and resigned. The investigation revealed that the employee had slapped the resident's face after the resident's head involuntarily touched the employee's nametag during a shirt change. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting of alleged violations to the appropriate authorities. However, there was a lack of communication and clarity in the administration's handling of the incident. The administrator was absent during the incident, and the regional support consultant reported the incident to the state agency. Despite the employee providing a written statement, it was reported that the employee had not given a statement because they did not meet with the administration in person.
Deficiency in Resident Transfer Documentation
Penalty
Summary
The facility failed to ensure proper documentation was provided during the transfer or discharge of residents, leading to deficiencies in the care process. Resident 8, who has multiple complex medical conditions including quadriplegia and stage four pressure ulcers, was transferred to the hospital on two occasions. On one occasion, no documents were sent with the resident, and on another, the documents provided were illegible, necessitating the reprinting of forms. This lack of proper documentation could potentially impact the continuity of care for the resident during hospital visits. Similarly, Resident 54, who suffers from end-stage renal disease and hypertension, was transferred to the emergency room due to chest pain and shortness of breath. However, the facility failed to provide the necessary transfer order and paperwork, including discharge and bed hold information. The facility's policy requires that specific information be provided to the receiving provider, but in this case, the documentation was not located, indicating a lapse in adherence to the established procedures.
Inaccurate MDS Assessment for Resident with Bladder Management Needs
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) assessment for a resident, identified as Resident 4, who was reviewed for unnecessary medications and bladder management. The resident's clinical record indicated diagnoses of cerebral palsy and flaccid neuropathic bladder. The Quarterly MDS assessment inaccurately documented that the resident had an indwelling, suprapubic, and external catheters with a colostomy, while a subsequent Significant Change MDS noted only an indwelling and suprapubic catheter, omitting the external catheter and colostomy. This discrepancy was acknowledged by the MDS nurse during an interview, who confirmed the need for correction. The facility's policy on conducting accurate resident assessments emphasizes the importance of reflecting the resident's status at the time of assessment and ensuring that qualified staff conduct these assessments. Despite this policy, the inaccuracy in Resident 4's MDS assessment was identified, indicating a lapse in adherence to the policy. The Regional Support Person acknowledged the facility's commitment to following the Resident Assessment Instrument (RAI) and the potential existence of a policy for MDS accuracy, yet the deficiency in the assessment process was evident.
Failure to Implement Physician Orders and Develop Care Plans for Medications
Penalty
Summary
The facility failed to implement physician orders and develop comprehensive care plans for three residents regarding unnecessary medications. Resident 4, who has diagnoses including major depressive disorder, anxiety, chronic pain, hypertension, and osteoarthritis, was found to have incomplete documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for monitoring side effects and interventions related to their medications. Specific dates in April, May, and June lacked documentation for pain monitoring, electrolyte imbalance, and side effects of antianxiety, antidepressant, and antipsychotic medications. Resident 9, diagnosed with dementia, anxiety, bipolar disorder, and major depressive disorder, also had incomplete documentation in the MAR and TAR. The facility failed to administer the Rivastigmine patch on several occasions and did not document reasons for missed doses of Diazepam. Additionally, there was a lack of documentation for monitoring side effects of antianxiety, antidepressant, antipsychotic, and mood stabilizer medications on specific dates in June. Resident 15, with a diagnosis of nonrheumatic aortic valve stenosis, was receiving an antiplatelet medication, Aspirin, but the clinical record lacked an order to monitor for side effects such as bleeding. Furthermore, there was no care plan addressing the use of antiplatelet medication or monitoring for bleeding. The Director of Nursing and MDS Coordinator acknowledged the absence of necessary documentation and care plans during interviews.
Improper Insulin Administration Due to Incorrect Priming Procedure
Penalty
Summary
The facility failed to ensure proper administration of insulin for a resident, as observed during a survey. On July 10, 2024, a Registered Nurse (RN) was seen preparing a Humalog Insulin Kwikpen for a resident with a blood glucose level of 200. The RN set the pen to administer 6 units of insulin, explaining that 4 units were for the resident's sliding scale insulin requirement and 2 units were to prime the pen. However, the RN administered all 6 units to the resident without following the correct priming procedure. Further investigation revealed discrepancies in staff understanding of insulin pen usage. A Licensed Practical Nurse (LPN) stated that insulin pens do not require priming, contradicting the Humalog Kwikpen user manual, which specifies that priming is necessary to ensure accurate dosing. The Director of Nursing confirmed that the pen should be primed with 2 units before administering the required dose. The facility's Insulin Pen policy also supported the need for priming, indicating a lack of adherence to established procedures.
Failure to Provide Restorative Services as Per Care Plans
Penalty
Summary
The facility failed to provide restorative services as outlined in the care plans for three residents, leading to a deficiency in maintaining or improving their range of motion (ROM). Resident 2, diagnosed with dementia, weakness, and intellectual disabilities, had a care plan for active range of motion (AROM) exercises for the bilateral lower extremities, initiated in September 2022. However, there were numerous documented dates in 2024 where no restorative AROM was provided, indicating a lapse in the prescribed care. Similarly, Resident 7, with Parkinson's disease and dementia, had a care plan for daily AROM exercises for the bilateral lower extremities, initiated in May 2023. The records showed multiple dates in 2024 where these exercises were not performed. Resident 13, diagnosed with end-stage renal disease, hypertension, and dementia, also had a care plan for AROM exercises for both upper and lower extremities, initiated in March 2024. Again, there were several dates in 2024 where the exercises were not conducted. The Occupational Therapist indicated that it was the nursing staff's responsibility to perform these restorative therapies, but the facility's policy required the restorative nurse to ensure the implementation of each resident's program.
Failure to Update Care Plan and Document Falls
Penalty
Summary
The facility failed to adequately reduce the risk of falls for a resident, identified as Resident 6, who had a history of multiple falls. The resident, who was cognitively intact and dependent on staff for transfers, had a history of hemiplegia and hemiparesis following a cerebral infarction, and was at risk for falls. Despite these known risks, the facility did not consistently update the resident's care plan with new interventions following each fall. For instance, after a fall on 7/20/23, the care plan was not updated with the intervention of laying out clothes to prevent reaching, and similar omissions occurred after subsequent falls. The documentation of falls and subsequent actions was inconsistent and incomplete. On several occasions, such as the fall on 8/14/23, the clinical record lacked a post-fall evaluation, IDT note, or updated care plan. Additionally, there were discrepancies in the documentation, such as the fall on 1/12/24, where the care plan was not updated despite staff education on safe transferring. The resident also experienced a significant fall on 6/11/24, resulting in a nose fracture, which was attributed to the call light being out of reach, yet the care plan was only updated after the incident. The facility's policies required that the care plan be reviewed and revised upon a resident's status change, including after falls. However, the facility did not consistently adhere to these policies, as evidenced by the lack of timely updates to the care plan and incomplete documentation of falls. The facility's failure to implement and document specific interventions to reduce fall risks contributed to the ongoing risk of falls for Resident 6.
Failure to Follow Dialysis Care Plan and Physician Orders
Penalty
Summary
The facility failed to adhere to physician orders and implement the care plan for a resident requiring hemodialysis. Resident 13, who was admitted with diagnoses including end-stage renal disease, hypertension, and dementia, had specific physician orders and care plans in place. These included obtaining weight after dialysis treatments on specified days and monitoring the left upper extremity for signs of infection due to a newly placed fistula. However, the facility did not consistently follow these orders. Blood pressure readings were repeatedly taken from the resident's restricted limb, where the fistula was located, despite clear instructions not to do so. Additionally, the facility failed to record the resident's weight after dialysis sessions on multiple occasions, as required by the physician's orders. The lack of adherence to these orders and care plans was confirmed through interviews with facility staff and a review of the resident's clinical records. The facility's policy on comprehensive care plans emphasized the importance of following physician orders to maintain the resident's well-being, yet there was no specific policy in place to ensure compliance with these orders.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, as evidenced by a meal tray test conducted on the 200 Unit Hall. The test revealed that the chicken thigh was at 126.5 degrees Fahrenheit, the potato at 125.5 degrees Fahrenheit, the cottage cheese at 48.2 degrees Fahrenheit, the dessert chocolate eclair pudding at 67.5 degrees Fahrenheit, and the salad at 53.6 degrees Fahrenheit. These temperatures did not meet the facility's policy, which requires hot foods to be held at 135 degrees Fahrenheit or greater and cold foods to be kept at or below 41 degrees Fahrenheit. Interviews with residents indicated dissatisfaction with the food temperatures. One resident mentioned that the food is cold, while another stated that the food is not always hot and that CNAs do not serve the food immediately. The Dietary Manager confirmed that the expected temperatures for meats and vegetables should be greater than 165 degrees Fahrenheit and cold items should be less than 41 degrees Fahrenheit. The facility's policy on food temperatures was provided by the Administrator, which aligned with these standards.
Failure to Ensure Safe Storage of Resident's Food
Penalty
Summary
The facility failed to ensure the safe storage of foods brought in externally for a resident, identified as Resident 8, who was reviewed for resident refrigerators. During an observation, it was noted that Resident 8's refrigerator had two blank temperature logs for June and July 2024 taped to the outside door, with no temperatures recorded. Resident 8, who was admitted with diagnoses including quadriplegia and contracture of muscle/joint, was cognitively intact but fully dependent on staff for eating, toileting, bathing, and transfers, as per the most recent Quarterly MDS Assessment. An interview with an LPN revealed that staff were supposed to record the temperature of resident room refrigerators each morning during rounds, but this was not done for Resident 8's refrigerator. The facility's policy, provided by the Regional Support Consultant, stated that resident-owned refrigerators must be inspected and maintain proper temperature, which was not adhered to in this case.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation for several residents, leading to deficiencies in medication administration and record-keeping. For Resident 15, a transcription error resulted in a duplicate medication order for sertraline, causing the resident to receive both a 100 mg tablet and a 50 mg tablet instead of a single 150 mg dose. This error was identified in the medication administration notes, but the confusion persisted until the Regional Nurse acknowledged the transcription mistake and the need for correction. Resident 8's clinical record lacked documentation for therapeutic leaves of absence, as staff did not consistently record when the resident left or returned to the facility. Additionally, there was no evaluation or physician's order for these leaves, contrary to the facility's policy. For Resident 26, discrepancies were found in the skin assessments, with a weekly review indicating intact skin despite a physician's order for treatment of an abrasion on the foot. The nurse responsible was unable to locate the wound or recall the treatment, highlighting incomplete and inaccurate documentation.
Inadequate Cleaning of Multi-Resident Use Glucometers
Penalty
Summary
The facility failed to ensure that multi-resident use glucometers were cleaned according to the manufacturer's instructions. During an observation, a registered nurse was seen cleaning a glucometer with a Micro-kill Bleach wipe for only 2 seconds before placing it back in the medicine cart. A qualified medication aide later indicated that the correct procedure was to wipe the glucometer for 30 seconds and let it air dry. The infection preventionist provided conflicting information, stating that the glucometer should be wrapped in a bleach wipe for 3 minutes. The facility's policy and the manufacturer's instructions both required the glucometer to remain wet for the contact time specified on the wipe's directions, which was 30 seconds according to the Micro-kill Bleach Wipes instructions. This inconsistency in cleaning practices led to the deficiency.
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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 Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Envive Of River City | 0.1 mi | ★★★★★ | 25 | 0 |
| Columbia Healthcare Center | 0.1 mi | ★★★★★ | 9 | 0 |
| Brickyard Healthcare - Brentwood Care Center | 1.4 mi | ★★★★★ | 2 | 0 |
| North Park Nursing Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Parkview Care Center | 1.9 mi | ★★★★★ | 25 | 0 |
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