Inspection Reports for
Brickyard Healthcare – Richmond Care Center

The complaint investigation substantiated that Resident E sexually abused Resident D and caused psychological harm to Resident F. Staff failed to implement behavioral interventions and increase supervision after Resident F was assigned as Resident E's roommate.

The facility failed to protect residents from sexual abuse and failed to implement appropriate behavioral health interventions for a resident with known inappropriate behaviors. Staff were unaware of necessary behavioral management interventions, and supervision was not increased after a roommate was assigned.

Complaint IN00453938 related to resident safety and accident hazards; Complaint IN00454495 related to resident records and documentation of death.

The facility failed to ensure safe transfers for a resident resulting in a severe leg laceration requiring sutures, and failed to properly document a resident's death including notification to the physician and family.

This citation relates to Complaint IN00453938 for the transfer injury and Complaint IN00454495 for failure to document a resident's death.

The facility failed to ensure adequate assistance and supervision during resident transfers, resulting in a resident sustaining an 18.5 cm laceration requiring 18 sutures. Additionally, the facility failed to document a resident's death and related notifications in the clinical record.

Complaint IN00446364 triggered the inspection. The complaint involved multiple issues including medication self-administration, code status documentation, resident privacy violations, smoking safety, medication crushing orders, drug regimen monitoring, medication storage, and hospice care coordination.

The facility was found deficient in several areas including failure to document self-administration of medications, improper code status orders and care plans, privacy violations due to unauthorized photos and videos, inadequate smoking safety measures, lack of physician orders for crushing medications, failure to monitor use of antianxiety medication, improper medication storage and labeling, and failure to ensure hospice orders and care plans were in place.

Complaint IN00446761 - No deficiencies related to the allegations cited. Complaint IN00446364 - Federal/State deficiencies related to the allegations cited at F554, F578, F583, F689, F755, F757, F761 and F849. Complaint IN00446019 - No deficiencies related to the allegations cited.

The facility was found deficient in multiple areas including failure to document clinically appropriate self-administration of medications, lack of proper code status orders and care plans, privacy violations by staff taking photos/videos on personal phones, failure to use smoking aprons for resident safety, lack of physician orders to crush medications, failure to monitor one-time medication orders, improper medication labeling and storage, and failure to maintain hospice orders and care plans.

The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements, with multiple deficiencies noted including obstructed egress, improper kitchen equipment placement, inaccessible fire department connection, malfunctioning corridor doors, and improper use of power strips.

This citation relates to Complaint IN00440948.

The facility failed to follow physician orders for obtaining daily and monthly weights for two residents and failed to have accurate skin assessments, follow orders for no brief while in bed, and have heels floated for one resident. Several residents had untreated or improperly managed skin issues and weight monitoring deficiencies.

Complaint IN00440948 was investigated during this survey, with federal/state deficiencies related to the allegations cited at F684.

The facility was found deficient in multiple areas including failure to ensure proper self-administration of medications, failure to provide fresh water daily, failure to follow physician orders for weights and skin assessments, failure to implement proper infection control precautions, and failure to provide appropriate skin care for residents.

This citation relates to Complaint IN00440948 regarding failure to provide appropriate skin care and other care deficiencies.

The facility failed to ensure proper self-administration medication assessments, provide fresh water daily, follow physician orders for skin care and weight monitoring, and implement infection control precautions for residents under contact isolation.

This citation relates to Complaints IN00440019 and IN00439896. The complaint involved failure to complete care plan meetings and medication issues related to antibiotic administration and monitoring.

The facility failed to complete care plan meetings for 2 of 3 residents reviewed and failed to notify the infectious disease physician of lab results and obtain required labs before continuing Vancomycin administration for 1 of 3 residents reviewed. The Vancomycin trough levels were not properly monitored, resulting in administration beyond the ordered stop date.

Complaint IN00440019 had deficiencies related to care plan meetings cited at F-553. Complaint IN00439896 had deficiencies related to medication administration cited at F-684. Complaints IN00437595, IN00435225, and IN00434048 had no deficiencies related to the allegations.

The facility was found deficient in completing care plan meetings for residents and their representatives, and in notifying a resident's infectious disease physician of lab results related to antibiotic administration. Some complaints had no deficiencies related to the allegations.

Complaint IN00433180 related to failure to develop a care plan for seizure-like activities. Complaint IN00432977 related to unsafe mechanical lift use causing a resident fall and fracture. Both complaints were substantiated with findings.

The facility failed to develop and implement a care plan for seizure-like activities for one resident and failed to ensure safe use of a mechanical lift by requiring two staff members, resulting in a fall and fracture for another resident. Corrective actions included staff education, care plan updates, and ongoing monitoring.

The investigation was triggered by Complaints IN00432977 and IN00433180. Deficiencies related to these complaints were cited at F689 and F656 respectively. The complaint investigation found the facility did not have a care plan for seizure-like activities for Resident C, substantiated by record review and interviews.

The facility failed to develop and implement a comprehensive care plan for seizure-like activities for one resident (Resident C) reviewed for falls. The Director of Nursing confirmed the absence of such care plans during the investigation.

This citation relates to Complaints IN00428308 and IN00429661. The investigation found substantiated deficiencies in pressure ulcer care and treatment for residents with skin integrity issues.

The facility failed to ensure timely treatment and services for residents with pressure ulcers and incontinence associated dermatitis, resulting in worsening and infected pressure ulcers for two residents reviewed. The deficient practices were corrected prior to the survey, including full skin assessments, staff education, and audits.

Complaints IN00417192, IN00421987, IN00430428, and IN00430802 had no deficiencies related to allegations. Complaints IN00428308 and IN00429661 were substantiated with deficiencies cited at F686 related to pressure ulcer care and treatment.

The facility was found deficient in providing timely treatment and services to residents with pressure ulcers and incontinence associated dermatitis, resulting in worsening and infected pressure ulcers for two residents reviewed. The facility had no deficiencies related to some complaints but cited deficiencies related to complaints IN00428308 and IN00429661 at F686. The facility had corrected the deficient practice prior to the survey and implemented a wound management program.

Complaint IN00419162 involved failure to report abuse, failure to provide quality care including timely hospital transfer, and failure to provide oxygen therapy. Complaint IN00419396 involved failure to report abuse, inadequate staffing, infection control issues, and sanitary environment concerns.

The facility was found deficient in multiple areas including failure to report and protect residents from abuse, inadequate quality of care for residents with changes in condition, failure to provide oxygen therapy per physician orders, insufficient nursing staff to meet resident needs, failure to prevent a staff member with gastrointestinal illness from working, and failure to maintain a sanitary environment as evidenced by a meal tray with maggots found in a resident's room.

This citation relates to Complaint IN00419396 and Complaint IN00419162. The investigation found substantiated abuse allegations, inadequate care, staffing shortages, infection control violations, and unsanitary conditions.

The facility failed to report abuse allegations timely, provide appropriate treatment and care, ensure oxygen therapy per physician orders, maintain adequate staffing levels, prevent staff from working while ill, and maintain sanitary conditions. Several residents experienced neglect, inadequate supervision, and unsafe conditions.

The deficiencies relate to complaints IN00418127, IN00418156, IN00409817, IN00415222, and IN00418208 regarding inadequate resident care and documentation.

The facility failed to ensure a dependent resident received proper toileting assistance, resulting in a fall. It also failed to conduct timely skin assessments and initiate appropriate treatments for skin impairments in multiple residents. Additionally, the facility did not maintain complete documentation of medication administration and treatment records for residents with skin impairments.

The investigation was triggered by complaints IN00409817, IN00415222, IN00417608, IN00418127, IN00418156, and IN00418208. Deficiencies related to these complaints were cited at tags F677, F686, and F842. Some complaints had no deficiencies related to the allegations.

The facility was found deficient in ensuring dependent residents received proper assistance with activities of daily living, timely and appropriate treatment and assessment of skin impairments, and complete and accurate documentation of medical and treatment records. Several residents had issues related to toileting assistance, pressure ulcer prevention and treatment, and medical record documentation.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards including deficiencies in emergency preparedness planning, emergency power system maintenance, egress door locking, corridor door latching, smoke barrier door functionality, occupational therapy office smoke detection, and smoking area maintenance.

Complaint IN00406095 and IN00407646 were substantiated with federal/state deficiencies cited at F677. Complaint IN00408060 was substantiated with deficiencies cited at F600.

The facility was found deficient in multiple areas including reasonable accommodations, abuse/neglect policies, notice requirements before transfer/discharge, accuracy of assessments, comprehensive care plans, activities of daily living, activities programming, quality of care, dialysis services, infection control, immunizations, and personnel files. Specific issues included failure to provide specialty cups, delayed abuse reporting, incomplete transfer documentation, inaccurate MDS assessments, incomplete care plans, inadequate ADL care, lack of activity engagement, delayed pain management, incomplete dialysis documentation, incomplete infection surveillance, and missing employee file documentation.

The complaint investigation included allegations of abuse, neglect, failure to provide ordered care and services, inadequate supervision, failure to follow physician orders, and failure to provide immunizations.

The facility failed to provide ordered specialty cups and whirlpool baths, failed to prevent abuse and neglect of residents including physical and verbal abuse, failed to ensure timely reporting of abuse, failed to provide appropriate transfer and discharge notifications, failed to complete accurate assessments and care plans, failed to provide adequate activities and supervision, failed to follow physician orders for splints and weights, failed to provide appropriate pain management, failed to monitor feeding tube intake, failed to ensure infection control surveillance, and failed to provide immunizations as required.

The complaint involved allegations of physical and verbal abuse of Resident B by staff, failure to report the abuse timely, and inadequate care for residents' activities of daily living and dementia-related behaviors. The abuse was substantiated with video evidence and interviews. The facility took corrective actions including staff termination and education.

The facility failed to protect a resident with dementia from physical and verbal abuse by staff, resulting in bruising and trauma response. The facility also failed to timely report the abuse to the appropriate authorities. Additionally, deficiencies were found in providing adequate dementia care and assistance with activities of daily living for several residents.

This visit was complaint-related for complaints IN00404542, IN00404629, and IN00405188. Deficiencies were substantiated as cited in the report.

The facility was found deficient in multiple areas including failure to provide fluids throughout the day for residents, failure to conduct weekly skin assessments and timely catheter care, failure to administer intravenous antibiotics timely and fully, and incomplete documentation in medication and treatment records as well as lack of readmission assessments.

This Federal deficiency relates to Complaints IN00404542, IN00404629, and IN00405188.

The facility failed to provide adequate hydration to residents, ensure timely skin assessments and catheter care, administer intravenous antibiotics and emergency drug kit medications timely, and maintain complete and accurate medical documentation for multiple residents.

Complaint IN00387720 was unsubstantiated due to lack of evidence. Complaint IN00388299 was substantiated with no deficiencies cited. Complaint IN00391807 was unsubstantiated due to lack of evidence. Complaint IN00394742 was substantiated with federal/state deficiencies cited at F580 and F684. Complaint IN00400058 was substantiated with no deficiencies cited.

The facility was found to have substantiated deficiencies related to notification of changes in condition and quality of care for Resident F, including failure to follow up on significant laboratory changes, failure to obtain daily weights, and failure to assist with a cardiology appointment as ordered. Some complaints were unsubstantiated or substantiated with no deficiencies cited.

The facility was found deficient in multiple areas including failure to provide dignified care, respect resident preferences, prevent verbal abuse, accurately assess and plan care, assist with activities of daily living such as bathing and showering, timely incontinent care, proper wound care, medication administration, infection control practices including PPE use, feeding tube management, staff training on abuse prevention, and adequate staffing levels to meet resident needs.