Inspection Reports for
Brickyard Healthcare – Petersburg Care Center

The facility failed to ensure timely physician notification of significant weight loss and skin tears for residents, did not provide adequate oral hygiene care for a resident with dentures, employed a dietary manager without current certification, and failed to maintain proper infection control practices during wound care.

The facility was found not in compliance with Life Safety Code requirements, specifically failing to ensure the fire department connection had proper signage and the oxygen storage room had a working mechanical ventilation system. Corrective actions were planned and requested for paper compliance.

Complaint IN00437005 was investigated during this visit, with federal/state deficiencies related to the allegations cited at F921.

The facility was found deficient in accommodating resident needs for call lights, accuracy of Minimum Data Set (MDS) assessments, dialysis care and documentation, and maintaining a safe, clean, and homelike environment including water temperature control and room maintenance.

This citation relates to Complaint IN00437005.

The facility failed to ensure safe and appropriate dialysis care for one resident, including lack of post dialysis assessment documentation and absence of a current dialysis contract. Additionally, the facility failed to maintain a clean and homelike environment in several resident rooms and shower rooms, with issues such as holes in walls, exposed pipes, uncovered bedpans, and excessively high water temperatures.

This inspection was complaint-related, investigating issues including call light accessibility, MDS assessment accuracy, dialysis care and documentation, and environmental safety and cleanliness. The complaint number referenced is IN00437005.

The facility failed to ensure call lights were accessible to residents, accurate MDS assessments were completed, post-dialysis assessments were documented, and the environment was safe and homelike. Multiple residents were affected by these deficiencies, including issues with call light accessibility, inaccurate clinical records, lack of dialysis post-assessment documentation, and unsafe water temperatures and unclean conditions in resident rooms and shower areas.

Complaint IN00415321 was substantiated with federal/state deficiencies cited. Complaint IN00420720 was not substantiated with no deficiencies cited.

The facility failed to ensure treatment orders were put in place and weekly wound measurements were documented for one of three residents reviewed (Resident B). Resident B had diabetic foot ulcers and chronic osteomyelitis, but wound treatment orders were missed and wound measurements were not consistently recorded. The resident was non-compliant with treatments and missed wound clinic appointments. The facility lacked documentation of notifying the physician about missed appointments and non-compliance.

This citation relates to Complaint IN00415321. Resident B was non-compliant with wound care, missed multiple wound clinic appointments, and the facility failed to document or notify the physician about these issues.

The facility failed to ensure treatment orders were implemented and weekly wound measurements were documented for Resident B. Resident B was non-compliant with wound care, missed wound clinic appointments, and there was no documentation of nursing staff notifying the physician about missed appointments or non-compliance.

The visit was conducted in conjunction with the investigation of Complaint IN00413866.

The facility failed to ensure a safe and sanitary environment to prevent the development and transmission of infections. Specifically, nursing staff did not wear proper personal protective equipment (PPE) during incontinence care and insulin administration for residents on Enhanced Barrier Precautions (EBP).

This Federal tag relates to complaint IN00413866.

The facility failed to ensure staff had the skills, experience, and knowledge to provide proper PICC line care for two residents. Residents missed ordered antibiotic doses, lab results were not obtained timely, and staff were not in-serviced on PICC line care.

Complaint IN00413866 was substantiated with federal/state deficiencies cited. Complaint IN00412618 had no deficiencies related to allegations.

The facility failed to ensure staff had the skills, experience, and knowledge to provide care related to PICC line services for 2 residents. Residents missed antibiotic doses, lab results were not obtained timely, and staff were not in-serviced on PICC line care.

The facility was found deficient in multiple areas including failure to notify physicians and family of significant resident condition changes, respiratory care deficiencies, inaccurate nurse staffing postings, medication errors, unappetizing food served at unsafe temperatures, and inadequate infection control practices.

The investigation was complaint-driven, focusing on failure to notify physicians and family of resident condition changes, respiratory care deficiencies, medication errors, food quality issues, staffing information accuracy, and infection control breaches. Substantiation status is not explicitly stated.

The facility failed to notify physicians and family members of significant resident condition changes, did not follow physician oxygen orders or document oxygen use properly, had medication errors exceeding 5%, provided unappetizing and improperly tempered food, posted inaccurate nurse staffing information, and failed to maintain proper infection control practices during medication administration and incontinence care.