Inspection Reports for
Brickyard Healthcare – Elkhart Care Center

This citation relates to Intake 27044933. The complaint involved failure to notify Resident B's personal representative of new orders and changes in condition, and failure to follow physician's medication orders.

The facility failed to notify the personal representative of Resident B about new medical orders and changes in condition. Additionally, the facility did not follow physician's orders regarding blood pressure medication administration for Resident B.

The complaint involved verbal abuse and neglect of Resident B by CNA 5. The incident was substantiated, resulting in CNA 5's suspension and termination. The local police cleared the case with no prosecution.

The facility failed to ensure Resident B was free from verbal abuse by CNA 5, who was observed screaming and engaging in a verbal altercation with the resident. CNA 5 was removed from the facility and terminated following the incident.

The inspection was complaint-related, addressing complaints IN00462615, IN00461580, 1547766, and 1547767.

The facility was found deficient in maintaining a clean and sanitary environment, proper medication administration and documentation, timely care planning, range of motion interventions, pharmaceutical services, and food safety practices.

This citation relates to Complaint IN00451700. The allegation involved Employee 3 spraying a resident with room deodorizer and pushing the spray can into the resident's rectum. The facility failed to report the allegation within the required timeframe.

The facility failed to timely report an allegation of abuse for one of three residents reviewed. The Administrator was not informed immediately by an employee who first received the abuse report, delaying the required notification and investigation.

Complaint IN00451700 was substantiated with federal/state deficiencies cited related to the allegations of abuse involving Resident B. The allegation was reported late by Employee 6, who failed to immediately notify the Administrator as required.

The facility failed to implement their policy related to reporting an allegation of abuse for 1 of 3 residents reviewed (Resident B). The allegation involved an employee spraying a resident with room deodorizer and inappropriate conduct. The facility suspended the employee, reported the incident to the State Agency, and initiated an investigation. The Administrator acknowledged a failure in timely reporting by a staff member.

Complaint IN00443191 was substantiated with Federal/State deficiencies cited at F804 related to food temperature issues. Other complaints (IN00443784, IN00443631, IN00443636, IN00443671) had no deficiencies related to allegations.

The facility was found deficient related to Complaint IN00443191 for failing to ensure food was served at palatable temperatures in the main kitchen, potentially affecting 110 of 120 residents. Other complaints had no deficiencies cited.

This citation relates to Complaint IN00443191.

The facility failed to ensure hot foods were served at safe and palatable temperatures, with multiple observations showing food temperatures below the required minimum. Residents reported that hot food was often served cold.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including deficiencies in emergency communication plans, egress door accessibility and signage, sprinkler system installation and maintenance, fire department connection visibility, smoking regulations, and staff training on oxygen transfilling procedures.

Complaint IN00438189 and IN00435892 were investigated with no deficiencies related to the allegations cited.

The facility was found deficient in multiple areas including management of resident funds, baseline and comprehensive care plans, activities, quality of care related to edema and antibiotic administration, infection control, medication management, and food handling. No deficiencies were cited related to the complaints investigated.

The facility had multiple deficiencies including failure to ensure resident funds availability, inadequate surety bond coverage, incomplete advanced directive orders, delayed baseline and comprehensive care plans, lack of resident-centered activities, inadequate monitoring and treatment of edema and infections, failure to provide range of motion programs, improper PICC line care, inadequate tracheostomy care, missing controlled substance count verifications, inappropriate use of antipsychotic medication, improper food handling, and failure to follow infection control practices.

The facility was found not in compliance with emergency preparedness requirements related to generator testing and inspections, life safety code requirements including sprinkler coverage, exit door locking and signage, fire alarm system maintenance, corridor door latching, fire drills, generator maintenance and testing, power strip usage, and oxygen transfilling procedures.

This Federal tag relates to Complaint IN00412325. The complaint involved issues with medication administration observation, timely physician notification of missed medications, and medication availability from the pharmacy.

The facility failed to ensure residents were visually observed taking medications and failed to notify physicians timely about missed doses due to unavailable medications for multiple residents. Additionally, the facility did not ensure medications were consistently available from the pharmacy for residents reviewed for pain management.

This Federal tag relates to Complaint IN00412325. The investigation included multiple complaints about medication management, resident care, environmental safety, and food safety.

The facility was found deficient in multiple areas including incomplete Physician Orders for Scope of Treatment forms, failure to notify physicians timely of missed medications, lack of transfer documentation, incomplete care plans for respiratory devices, inadequate shower provision, improper sanitation of CPAP equipment, medication availability issues, unsafe medication storage, food safety violations including expired and improperly stored foods, and environmental safety hazards such as broken equipment and mold.

Complaint IN00412325 - Federal/state deficiencies related to the allegations are cited at F755. Complaint IN00413904 - No deficiencies related to the allegations are cited.

The facility was found deficient in multiple areas including medication administration, advance directive documentation, notification of medication availability issues, transfer documentation, care planning for CPAP use, timely shower provision, sanitation of CPAP equipment, medication availability, medication storage and labeling, food safety and sanitation, and environmental safety and maintenance.

Complaint IN00407017 was substantiated with deficiencies cited related to the allegations. Complaints IN00404852 and IN00405551 had no deficiencies related to the allegations.

The facility failed to provide appropriate supervision and the correct textured diet for one resident on a mechanically altered diet, which resulted in the resident's death due to choking. The investigation revealed that the resident was served inappropriate food items such as potato chips and cheese puffs, which were not suitable for the prescribed mechanical soft diet.

This Federal tag relates to complaint IN00407017. The complaint involved failure to provide appropriate supervision and diet consistency for Resident B, which led to choking and death. The complaint was substantiated by the investigation.

The facility failed to provide proper supervision and served inappropriate food items to Resident B on a mechanically altered diet, leading to choking and death. The investigation revealed that prohibited items like potato chips and cheese puffs were served, and emergency response was initiated but unsuccessful.

The investigation was triggered by multiple complaints (IN00383064, IN00383207, IN00383543, IN00386854, IN00391650, IN00393676, IN399522, IN00400925, IN00401849, IN00401943). Several complaints resulted in cited deficiencies related to quality of care, wound care, catheter care, and other regulatory issues.

The facility was found to have multiple deficiencies including failure to provide written notice of roommate changes, inadequate monitoring and treatment of wound VAC therapy, failure to prevent pressure ulcer deterioration, inadequate catheter care leading to infection and sepsis, failure to monitor diuretic therapy, and lack of quarterly QAPI meetings.

The inspection was complaint-driven, related to complaints IN00383543 and IN00400925 concerning roommate notification failures, wound care deficiencies, catheter care failures, and medication monitoring issues. Immediate jeopardy was identified related to pressure ulcer care and catheter care, which was removed after corrective actions.

The facility failed to ensure written notice of roommate changes for residents assigned to rooms certified for one resident but occupied by two, failed to monitor and follow physician orders for wound VAC therapy resulting in wound deterioration and hospitalization, failed to provide appropriate pressure ulcer care leading to immediate jeopardy and resident death, failed to provide adequate catheter care resulting in sepsis and death, failed to monitor electrolyte levels for a resident on diuretics, and failed to conduct required quarterly QAPI meetings.