Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 - Woodlands Care Center during CMS and state inspections, most recent first.
Surveyors found that food was not served in a sanitary manner, with soiled kitchen equipment and floors, debris on surfaces, and unlabeled partially used food items in the freezer. The Dietary Manager confirmed that opened food should be labeled and that kitchen staff are responsible for regular cleaning, but these practices were not followed.
A resident with mild cognitive impairment and anxiety disorder was not permitted to attend a resident council meeting after expressing a desire to participate. An LPN removed the resident from the meeting area, stating she was not on the attendance list, even though facility policy allows all residents to participate and the resident was a regular attendee. The resident's care plan supported involvement in activities, and she was documented as oriented and without behavioral issues.
A resident with an indwelling catheter was observed on multiple occasions with the catheter bag either on the floor or touching the floor, contrary to the care plan and infection control policy. The resident was dependent on staff for toileting and had a diagnosis of neurogenic bladder. The Infection Preventionist confirmed that catheter bags should not be on the floor.
A facility failed to follow Enhanced Barrier Precautions during Foley Catheter care for a resident with severe cognitive impairment and an indwelling catheter. Staff did not wear gowns as required, despite signage and policy indicating the necessity for gown and glove use to prevent the transmission of multidrug-resistant organisms.
The facility failed to maintain resident dignity and privacy during meal service and medical interactions. Staff entered residents' rooms without knocking or announcing themselves, and an LPN applied clothing protectors without consent. Additionally, a physician conducted medical assessments in a common area, compromising confidentiality.
In the ACU, a treatment cart was found with improperly stored and labeled medications affecting nine residents. The medications, including creams and powders, were not stored in the medication room as required by facility policy. Interviews with the DON and an LPN confirmed the medications should have been labeled with the resident's name and open date.
The facility failed to maintain a sanitary environment, with observations of unclean sit-to-stand devices, mechanical lifts, and resident wheelchairs. Interviews revealed inconsistencies in cleaning practices, with CNAs responsible for equipment cleaning, contrary to the facility's policy.
The facility failed to implement care plans for two residents, leading to deficiencies in care. A resident with a history of falls was not provided with necessary fall prevention interventions, and staff were not informed about these measures. Another resident with Chronic Lung Disease was left in a flat bed position during treatment, contrary to physician orders, causing breathing difficulties. The facility's policies on care plans and supervision were not effectively communicated or implemented.
A facility failed to revise care plans for a resident with severe cognitive impairment and multiple diagnoses, including dementia and anxiety. Despite a biopsy on the resident's cheek, the care plan was not updated to include new wound care interventions. Additionally, the care plan for nutritional risk was not revised to reflect a physician's order for weekly weights. The facility's policy requires comprehensive, person-centered care plans with measurable objectives, which was not followed.
A facility failed to properly care for a resident with a PICC line, leading to a deficiency in IV therapy administration. The resident's care plan required weekly dressing changes and measurements of the catheter length, but these were not documented. Staff also took blood pressure readings from the arm with the PICC line, contrary to care plan instructions. The DON was unaware of the care plan's measurement requirements, and the facility's policy on measuring catheter length was not followed.
A resident with chronic respiratory conditions was not receiving oxygen at the prescribed flow rate, as observed during a facility survey. The oxygen concentrator was set at two liters instead of the ordered three liters. Additionally, staff repeatedly took blood pressure readings on the resident's restricted limb, contrary to the care plan. These actions were inconsistent with the facility's policy on oxygen administration and care plan adherence.
A facility failed to provide appropriate dialysis care for a resident with end-stage renal disease and diabetes. The resident's care plan was not followed, as staff took blood pressure readings from a restricted limb and did not consistently monitor fluid restrictions. Interviews revealed staff were unaware of the resident's specific care needs, leading to deficiencies in care.
A facility failed to document the assessment of UTI symptoms for a resident receiving IV therapy. The resident, admitted with multiple diagnoses, had an incomplete Admission MDS Assessment. Despite a care plan to observe for UTI signs, a progress note indicated symptoms like lower back pain and confusion, but follow-up documentation was missing until days later. The facility's policy required timely documentation, which was not followed.
The facility failed to implement proper infection control measures for two residents requiring enhanced barrier precautions and contact precautions. A resident with open wounds did not have an EBP sign on their door, and staff did not wear appropriate PPE during wound care. Another resident under contact precautions for shingles lacked a comprehensive care plan addressing these precautions. Facility policies on wound treatment and EBP were not followed, leading to deficiencies in infection control practices.
Failure to Maintain Sanitary Food Service and Proper Food Labeling
Penalty
Summary
Surveyors observed that the facility failed to serve food in a sanitary manner according to professional standards during two separate kitchen inspections. The top of the dish machine was found to be soiled, and the kitchen floors had debris buildup around the edges, under racks, tables, and the three-compartment sink. Additional debris was noted on a pull-down plug above the food prep table and on a wall-mounted fan. In the walk-in freezer, partially used bags of tater tots and potato wedges were stored in clear bags without any labeling. The Dietary Manager confirmed that opened food should be labeled with an open date and use-by date, and that kitchen staff are responsible for sweeping and mopping floors after each shift, while deep cleaning is performed monthly by housekeeping. The facility's policy requires labeling and dating of all food items removed from their original containers.
Resident Excluded from Resident Council Meeting Despite Expressed Interest
Penalty
Summary
A resident with a diagnosis of anxiety disorder and mild cognitive impairment was not allowed to participate in a resident council meeting, despite expressing a desire to attend. On the day of the meeting, the resident was observed in the main dining room and indicated to an LPN that she wanted to stay for the meeting. The LPN informed her that she was not on the list and removed her from the room, resulting in her absence from the meeting. The resident's care plan included interventions to involve her in out-of-room activities and to invite her to favorite and new activities, and records showed she was a regular member of the resident council and had attended previous meetings. Facility policy stated that all residents are eligible and encouraged to participate in resident council meetings. The administrator confirmed that anyone who was alert and oriented could attend, regardless of whether they were on the list. The resident was documented as oriented to person, place, and situation by psychiatry, and had no behaviors noted on her most recent MDS assessment. Despite this, the facility created a list for the meeting that only included residents deemed alert and oriented, and the resident was excluded from participation based on this list.
Failure to Maintain Proper Catheter Bag Placement for Infection Control
Penalty
Summary
A deficiency was identified when a resident with a history of neuromuscular dysfunction of the bladder and urinary retention, who was dependent on staff for toileting and had an indwelling catheter, was observed with improper catheter bag placement. On two separate occasions, the resident's catheter bag was either on the floor or hanging from the bed in such a way that it touched the floor. These observations were made while the resident was lying in bed, and the bed was in its lowest position during one of the incidents. Review of the resident's care plan indicated a specific intervention to keep the catheter drainage bag below the level of the bladder and off the floor at all times. The facility's policy on indwelling catheter use and removal also required adherence to professional standards of practice and infection prevention and control procedures. During an interview, the Infection Preventionist confirmed that catheter bags should not be on the floor, indicating a failure to follow established infection control practices and standards.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during the care of a resident with an indwelling urinary catheter. On the specified date, a Qualified Medication Aide (QMA) and a Certified Nursing Assistant (CNA) were observed providing Foley Catheter care to a resident without donning gowns, despite the presence of signage indicating the requirement for gown use. The resident's clinical record indicated severe cognitive impairment and the presence of an indwelling catheter, with care plans specifying the need for EBP during catheter care and other high-contact activities. The facility's policy on Enhanced Barrier Precautions, provided by the Administrator, outlined the necessity of gown and glove use to prevent the transmission of multidrug-resistant organisms, particularly for residents with indwelling medical devices. Despite this policy, the staff did not follow the required precautions during the observed care. The QMA later acknowledged that gowns and gloves should have been worn, indicating a lapse in adherence to the established infection control protocols.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of residents during meal service and medical interactions. Observations revealed that staff members, including CNAs, entered residents' rooms to deliver meal trays and beverages without knocking or announcing themselves. This occurred multiple times across different residents, indicating a pattern of behavior that disregards the residents' right to privacy and dignity. Additionally, during a meal observation, an LPN applied clothing protectors to residents without asking for their permission or explaining the action, further compromising the residents' dignity. Furthermore, a physician was observed conducting medical assessments in a common area where other residents, staff, and family members were present, which compromised the confidentiality of the residents' medical information. The facility's policy on promoting and maintaining resident dignity was not adhered to, as evidenced by these observations. The policy emphasizes the importance of treating residents with respect and maintaining their privacy, which was not followed in these instances.
Improper Storage and Labeling of Medications in ACU
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in the Alzheimer Care Unit (ACU), affecting nine residents. During an observation, a treatment cart was found to contain multiple medications that were either unlabeled or lacked an open date. These included various creams, ointments, and powders, some of which were not stored in the designated medication room as per facility policy. The medications were found in a locked nightstand/treatment cart, contrary to the facility's policy that requires all drugs and biologicals to be stored in locked compartments within the medication room. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that the medications should not have been stored in the treatment cart and should have been labeled with the resident's name, medical doctor, and medication name. Additionally, all medications, including ointments, creams, and powders, should have been dated with an open date. The facility's policy, as provided by the Regional Nurse, mandates that all medications be stored in medication rooms and only accessible to authorized personnel.
Deficiency in Maintaining a Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, staff, and the public, as evidenced by multiple observations of unclean equipment and resident wheelchairs over a three-day period. Specifically, sit-to-stand devices and mechanical lifts in various hallways were found with dust, fiber debris, and white residue on multiple occasions. Additionally, resident wheelchairs were observed with food debris and chocolate milk splatters, indicating a lack of regular cleaning and maintenance. Interviews with residents and staff revealed inconsistencies in the cleaning practices for resident-care equipment. A resident reported that staff do not regularly clean wheelchairs, while a CNA stated that wheelchairs are cleaned weekly and as needed. Another resident was unaware if their wheelchair was cleaned, and a housekeeper indicated that CNAs are responsible for cleaning equipment, not the housekeeping staff. The facility's policy on cleaning and disinfection of resident-care equipment was provided, which emphasized the importance of routine cleaning and disinfection by each user, but the observations and interviews suggest this policy was not consistently followed.
Failure to Implement Care Plans for Fall Prevention and Respiratory Support
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 24, who has a history of falls and various medical conditions including dementia and abnormal gait, was observed without the necessary fall prevention interventions in place. Despite a care plan indicating the use of wedge pillows to prevent falls from a recliner, staff failed to implement this intervention, as observed on multiple occasions. Staff members were not adequately informed about the resident's fall interventions, leading to a lack of consistent care. Similarly, Resident 351, diagnosed with Chronic Lung Disease, experienced a deficiency in care when the head of the bed was not elevated during a treatment, despite physician orders and a care plan indicating the necessity of this intervention to alleviate shortness of breath. The resident expressed difficulty breathing, yet the staff delayed in adjusting the bed position. The facility's policies on comprehensive care plans and accident supervision were not effectively communicated or implemented, resulting in these care deficiencies.
Failure to Revise Care Plans for Resident
Penalty
Summary
The facility failed to ensure that care plans were revised for one of the two residents reviewed, specifically Resident 45. The resident's clinical record indicated diagnoses including unspecified dementia and anxiety, with a severe cognitive impairment noted in the most recent Quarterly MDS assessment. The resident required supervision for transfer and mobility, with substantial help needed for mobility. Despite having a biopsy on the right cheek on 6/19/24, the care plan for a seborrheic lesion dated 8/8/23 was not updated to reflect the new wound care interventions. Additionally, the care plan for nutritional risk due to inadequate food and beverage intake, triggered by a 10% weight loss, was not revised to include the physician's order for weekly weights, which was initiated on 6/14/24. During an interview, the MDS RN stated that care plans should be updated for surgeries and biopsies, but this was not done in Resident 45's case. The facility's policy on comprehensive care plans requires the development and implementation of a person-centered care plan with measurable objectives and timeframes, which was not adhered to in this instance.
Deficiency in PICC Line Care and Monitoring
Penalty
Summary
The facility failed to provide proper care for a resident with a peripherally inserted central catheter (PICC) line, leading to a deficiency in the administration of IV therapy. Resident 302, who was admitted with diagnoses including infection of joint prosthesis, anxiety, and hypertension, had a care plan that specified the PICC line dressing should be changed weekly and measurements of the catheter length and arm circumference should be taken. However, the facility did not adhere to these care plan instructions. The clinical record review revealed that staff repeatedly took blood pressure readings from the resident's right arm, where the PICC line was inserted, despite the care plan's directive to avoid this arm. Additionally, there was a lack of documentation regarding the catheter length in the resident's clinical record, and the Director of Nursing was unaware of the reason for the care plan's requirement to measure the PICC line during dressing changes. The facility's policy, provided by the clinical regional nurse, indicated that the external length of the catheter should be measured to ensure it had not migrated, yet this was not being done. These oversights and inconsistencies in following the care plan and facility policy contributed to the deficiency in the resident's care.
Failure to Administer Oxygen as Ordered and Adhere to Fistula Care Plan
Penalty
Summary
The facility failed to ensure a resident was receiving oxygen as ordered by the physician. During an observation, it was noted that a resident was receiving oxygen via nasal cannula from an oxygen concentrator set at two liters, despite the physician's order for three liters. A registered nurse confirmed the discrepancy and adjusted the oxygen flow to the correct setting. The resident, who was cognitively intact, had been diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, and required continuous supplementary oxygen to prevent or relieve hypoxia. Additionally, the facility failed to adhere to the care plan regarding the resident's fistula care. The resident's care plan specified that blood pressure should not be taken on the arm with the fistula access site. However, records indicated that staff repeatedly took blood pressure readings on the restricted limb on multiple occasions. This oversight was contrary to the care plan and the facility's policy on oxygen administration, which emphasized adherence to physician orders and care plan interventions.
Deficiency in Dialysis Care and Fluid Management
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage renal disease and diabetes mellitus. The resident, who was moderately cognitively impaired and dependent on staff for assistance, had specific physician orders for dialysis and fluid restrictions. However, the clinical record lacked an order to obtain the resident's weight, which is crucial for monitoring fluid balance in dialysis patients. Additionally, the resident's electronic medication administration record showed that staff obtained blood pressure readings from the resident's restricted limb on multiple occasions, contrary to the care plan instructions. Interviews with facility staff revealed a lack of awareness and adherence to the resident's care plan. A CNA was unaware of which residents were on fluid restrictions, and an LPN indicated that nurses and CNAs should record fluid amounts for residents on fluid restrictions, but this was not consistently done. The facility's policy on hemodialysis care, which emphasizes adherence to professional standards and physician orders, was not followed, leading to deficiencies in the care provided to the resident.
Failure to Document UTI Assessment for Resident
Penalty
Summary
The facility failed to document the assessment for symptoms of a urinary tract infection (UTI) for a resident undergoing IV therapy. The resident, who was admitted with diagnoses including infection of joint prosthesis, anxiety, and hypertension, had an incomplete Admission MDS Assessment. The care plan initiated on 6/11/24 included observing for signs and symptoms of a UTI. However, a progress note on 6/24/24 indicated the resident complained of lower back pain, had ineffective pain medication, and showed signs of increased confusion and irritability, yet there was no follow-up documentation of these symptoms or the order request until 6/28/24. The clinical record lacked documentation of a bowel assessment and the need for Miralax administration. During an interview, the Regional Clinical Nurse confirmed that the resident received an order for PRN Miralax for possible UTI symptoms. The facility's policy on documentation required that all assessments, observations, and services be documented in the resident's medical record at the time of service or no later than the shift in which they occurred, which was not adhered to in this case.
Inadequate Infection Control and Precautionary Measures
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for two residents requiring enhanced barrier precautions (EBP) and contact precautions. During an observation of wound care for Resident 352, it was noted that the nursing staff did not follow EBP protocols. Specifically, there was no EBP sign on the resident's door, and the staff did not wear the appropriate personal protective equipment (PPE) such as gowns, masks, or goggles during high-contact activities, despite the resident having open wounds. The resident's clinical records indicated multiple open lesions requiring daily dressing changes, which were not consistently followed as per physician orders. For Resident 45, who was under contact precautions due to shingles, the facility failed to develop a comprehensive care plan that included contact precautions. Although a contact precautions sign was present on the resident's door, the care plan lacked specific interventions for managing the resident's condition. The facility's policies on wound treatment management and enhanced barrier precautions were not adhered to, leading to deficiencies in infection control practices.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Newburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Grove Rehabilitation Center | 1 mi | ★★★★★ | 7 | 0 |
| Hamilton Pointe Health And Rehab | 1.8 mi | ★★★★★ | 4 | 0 |
| Majestic Care Of Newburgh | 2.2 mi | ★★★★★ | 0 | 0 |
| Newburgh Health And Rehab | 2.4 mi | ★★★★★ | 29 | 0 |
| River Pointe Health Campus | 4.7 mi | ★★★★★ | 1 | 0 |
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