Deficiencies (last 3 years)
Deficiencies (over 3 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
202% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 10
Date: Aug 8, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare regulations and standards at Brickyard Healthcare - Merrillville Care Center.
Findings
The facility was found deficient in multiple areas including medication administration, care planning, activities of daily living assistance, catheter care, respiratory care, pharmaceutical services, medication error rates, kitchen sanitation, infection prevention and control, and environmental maintenance. Deficiencies were generally of minimal harm or potential for actual harm affecting a few to many residents.
Deficiencies (10)
F0605: The facility failed to ensure interventions were attempted prior to administering PRN anti-anxiety medication for 1 of 3 residents reviewed for mood/behavior.
F0656: The facility failed to ensure a care plan was developed and in place for a resident receiving anti-anxiety medication for 1 of 33 residents reviewed for care plan development.
F0677: The facility failed to ensure a dependent resident received required assistance with activities of daily living related to dirty, uncut fingernails.
F0690: The facility failed to ensure an indwelling urinary catheter bag and tubing were kept off the floor for 1 of 2 residents reviewed for urinary catheters.
F0695: The facility failed to ensure a resident received necessary care related to oxygen administration due to unclear physician orders.
F0755: The facility failed to ensure a narcotic pain medication was obtained and administered as ordered and PRN medications were accurately recorded for 1 of 5 closed records reviewed.
F0759: The facility failed to ensure medication error rates were less than 5%, resulting in a 7.41% error rate during medication administration observation.
F0812: The facility failed to maintain a sanitary kitchen related to inadequate testing of the chemical dishwasher solution.
F0880: The facility failed to ensure infection control guidelines were implemented related to incorrect use of alcohol wipes during insulin administration and lack of physician orders for contact isolation for residents.
F0921: The facility failed to ensure the residents' environment was clean and in good repair related to discolored ceiling tiles, dirty vents, broken curtains, peeling wallpaper, gouges in walls, and marred floors in multiple units.
Report Facts
Medication error rate: 7.41
Medication administration opportunities: 27
Medication errors observed: 2
Dishwasher wash temperature: 160
Dishwasher rinse temperature: 150
Dishwasher sanitizing solution ppm: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Observed medication administration errors and interviewed regarding medication crushing. |
| RN 2 | Registered Nurse | Interviewed regarding catheter bag placement and correction. |
| RN 3 | Registered Nurse | Observed incorrect use of alcohol wipes during insulin administration. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication documentation and care plans. |
| MDS Nurse | MDS Nurse | Interviewed regarding care plan requirements and resident fingernail care. |
| Dietary Service Manager | Dietary Service Manager | Interviewed and observed dishwasher chemical testing. |
| Regional Maintenance Director | Regional Maintenance Director | Interviewed regarding environmental maintenance deficiencies. |
| Housekeeping Manager | Housekeeping Manager | Interviewed regarding environmental maintenance deficiencies. |
| [NAME] President of Regulatory Compliance | President of Regulatory Compliance | Interviewed regarding medication administration and infection control concerns. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 3, 2025
Visit Reason
The inspection was conducted following complaints regarding an alleged physical abuse incident between two residents at the facility.
Complaint Details
The complaint investigation was substantiated. Resident B sustained injuries from an assault by Resident C. Police were involved, and the facility conducted interviews and assessments. Resident C denied the assault but was found to be the perpetrator after investigation.
Findings
The facility failed to protect a cognitively impaired resident from physical abuse by his roommate, resulting in multiple injuries requiring hospital treatment. The investigation included interviews, record reviews, and police involvement, confirming the roommate as the perpetrator.
Deficiencies (1)
F 0600: The facility failed to protect a resident from physical abuse by another resident, resulting in swelling, discoloration, lacerations, and injuries requiring sutures. The facility did not prevent or adequately monitor to avoid the abuse.
Report Facts
Injury measurements: 2
Injury measurements: 0.9
Sutures: 6
Date of incident: Dec 29, 2024
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 2, 2024
Visit Reason
The inspection was conducted in response to Complaint IN00439994 regarding concerns about discharge planning and medication management at Brickyard Healthcare - Merrillville Care Center.
Complaint Details
This citation relates to Complaint IN00439994.
Findings
The facility failed to implement a complete discharge planning process ensuring follow-up on abnormal wound culture results for one resident and failed to manage medications appropriately for two residents, including medications not signed out or administered as ordered.
Deficiencies (2)
F0660: The facility failed to ensure discharge needs were met related to lack of ongoing physician follow-up for an abnormal wound culture result prior to discharge for 1 of 3 residents reviewed for skin conditions.
F0684: The facility failed to ensure medications were managed appropriately related to medications not signed out and given as ordered for 2 of 3 residents reviewed for unnecessary medications.
Report Facts
Residents affected: 1
Residents affected: 2
Wound culture sample date: Jul 10, 2024
Wound culture result date: Jul 14, 2024
Medication administration dates missed: 7
Antibiotic administration missed dates: 3
Inspection Report
Routine
Deficiencies: 10
Date: Jun 14, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate assistance with activities of daily living, failure to ensure access to vision services, improper resident transfers, incorrect feeding tube care, improper oxygen administration, inadequate pain management follow-up, medication regimen issues, unsanitary food service conditions, and failure to maintain a sanitary environment in the kitchen.
Deficiencies (10)
F 0677: The facility failed to ensure dependent residents received help with activities of daily living related to buildup on teeth for 1 of 7 residents reviewed.
F 0685: The facility failed to ensure residents with impaired vision received necessary services for 1 of 1 resident reviewed.
F 0689: The facility failed to ensure a dependent resident was transferred with a Hoyer mechanical lift as indicated for 1 of 1 resident reviewed for accidents.
F 0693: The facility failed to ensure gastrostomy tube care was completed as ordered related to incorrect enteral feeding administration for 1 of 3 residents reviewed.
F 0695: The facility failed to ensure a resident received proper care related to oxygen administration flow rate for 1 of 1 resident reviewed.
F 0697: The facility failed to ensure follow-up for a pain specialist's medication order was completed for 1 of 1 resident reviewed for pain.
F 0756: The facility failed to update physician's orders after a medication regimen review for 1 of 5 residents reviewed for unnecessary medications.
F 0757: The facility failed to ensure medication regimens were free from unnecessary drugs and failed to document blood sugar levels and insulin administration for 2 of 5 residents reviewed.
F 0812: The facility failed to serve food under sanitary conditions related to dirty and greasy food equipment, dust accumulation, food spillage, lack of hair restraints, improper glove use, and a malfunctioning dishwasher gauge in the main kitchen.
F 0921: The facility failed to maintain a sanitary environment related to dust and debris accumulation on floors, piping, fan blades, and loose baseboards in the main kitchen.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Named in oral care deficiency for Resident 54 | |
| CNA 2 | Named in improper transfer deficiency for Resident 113 | |
| D Unit Manager | Named in transfer deficiency and pain management follow-up | |
| Director of Nursing | DON | Named in multiple deficiencies including feeding tube care, pain management, and insulin documentation |
| Nurse Consultant | Interviewed regarding oral care, oxygen administration, and other findings | |
| Dietary Food Manager | DFM | Named in food service sanitation deficiencies |
| Dietary Employee 1 | Observed in food handling deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 4, 2024
Visit Reason
The inspection was conducted in response to Complaint IN00427763 concerning pressure ulcer care and infection prevention and control practices at the facility.
Complaint Details
This citation relates to Complaint IN00427763.
Findings
The facility failed to ensure proper treatment and assessment of pressure ulcers for two residents and did not implement adequate infection control practices during wound care, including improper glove use and hand hygiene violations.
Deficiencies (2)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents, including failure to administer treatment as ordered and incomplete pressure ulcer assessments upon admission.
F 0880: The facility failed to implement an infection prevention and control program, demonstrated by inadequate hand hygiene, improper glove use, and contamination of wound care supplies during dressing changes.
Report Facts
Pressure ulcer measurements: 5.5
Pressure ulcer measurements: 7
Pressure ulcer measurements: 1
Pressure ulcer counts: 3
Pressure ulcer counts: 2
Pressure ulcer measurements: 9
Pressure ulcer measurements: 11
Pressure ulcer measurements: 0.4
Pressure ulcer measurements: 4
Pressure ulcer measurements: 0.3
Pressure ulcer measurements: 3
Pressure ulcer measurements: 7
Pressure ulcer measurements: 5
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse 1 | Named in findings related to improper wound care and infection control practices | |
| Director of Nursing | Director of Nursing | Interviewed regarding missing wound assessments and policies |
| Wound Specialist NP | Nurse Practitioner Wound Specialist | Conducted wound assessments and provided treatment guidance |
| ADON | Assistant Director of Nursing | Observed wound care and clarified physician orders |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of inadequate pressure ulcer care and infection prevention practices at the facility.
Complaint Details
This citation relates to Complaint IN00419359.
Findings
The facility failed to ensure appropriate treatment and follow-up for pressure ulcers in one resident and failed to properly implement infection prevention measures related to COVID-19 PPE use in an isolation room.
Deficiencies (3)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one of three residents reviewed. Treatment recommendations were not implemented and no treatment orders were in place for pressure ulcers on the left heel and right hip of Resident F.
F 0686: The Wound Nurse did not follow up with the Nurse Practitioner to implement wound care treatment recommendations, resulting in no treatment orders being put into place for Resident F's pressure ulcers.
F 0880: The facility failed to properly prevent and contain COVID-19 by not ensuring staff wore all required PPE, including eye protection and gloves, when entering an isolation room for a resident with COVID-19.
Report Facts
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Observed pressure ulcers with Resident F | |
| Wound Care Nurse Practitioner | Provided wound care assessment and treatment recommendations for Resident F | |
| Wound Nurse | Did not implement wound care treatment recommendations or follow up with Nurse Practitioner | |
| Administrator | Interviewed regarding wound care and follow-up | |
| Infection Preventionist (IP) | Interviewed regarding PPE use and infection control | |
| CNA 1 | Observed not wearing required PPE when entering isolation room |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 11, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and other health and safety standards at Brickyard Healthcare - Merrillville Care Center.
Findings
The facility was found deficient in multiple areas including failure to provide adequate activities of daily living care, improper oxygen administration, medication errors including unnecessary medications and failure to notify physicians of abnormal lab results, delayed dental services, and inadequate infection prevention and control practices.
Deficiencies (7)
F 0677: The facility failed to provide ADL care related to long, dirty fingernails for a dependent resident (Resident 98).
F 0695: The facility failed to ensure proper oxygen administration flow rate for a resident (Resident 102), with oxygen concentrator turned off and incorrect flow rate initially.
F 0757: The facility administered blood pressure medication outside prescribed parameters for Resident 98, without proper monitoring.
F 0758: The facility failed to implement non-pharmacological interventions before administering antipsychotic medication and maintained a PRN order longer than 14 days for Resident 30.
F 0773: The facility failed to notify the physician of an abnormal theophylline lab result for Resident 98 in a timely manner.
F 0791: The facility delayed scheduling dental extraction procedures for Resident 34 despite documented need.
F 0880: The facility failed to implement infection control guidelines related to uncovered respiratory masks and failure to clean shared blood pressure cuffs and pulse oximeters between residents.
Report Facts
Medication administration dates outside parameters: 10
Medication administration dates: 24
Abnormal lab result: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding ADL care, medication administration, and infection control findings | |
| Administrator | Interviewed regarding multiple findings including ADL care, medication administration, dental services, and infection control | |
| RA 1 | Restorative Aide | Named in relation to trimming and cleaning Resident 98's fingernails |
| RN 1 | Registered Nurse | Notified and adjusted oxygen concentrator flow rate for Resident 102 |
| LPN 1 | Licensed Practical Nurse | Observed failing to clean blood pressure cuff and pulse oximeter between residents |
| Social Service Director | Interviewed regarding difficulty in scheduling dental services for Resident 34 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 19, 2023
Visit Reason
The inspection was conducted in response to complaints regarding the facility's failure to schedule physician appointments, provide appropriate respiratory care, and maintain accurate medical records.
Complaint Details
This Federal tag relates to Complaint IN00401074 for F0684 and Complaint IN00408440 for F0695. The report documents substantiated issues related to scheduling and care deficiencies.
Findings
The facility failed to schedule required physician appointments, properly assess residents before and after nebulizer treatments, and maintain accurate and complete medical records for multiple residents. Documentation deficiencies and delays in referrals and medication administration were also noted.
Deficiencies (3)
F 0684: The facility failed to schedule a physician appointment as ordered for 1 of 3 residents reviewed. Resident G's nephrologist appointment was not scheduled as required.
F 0695: The facility failed to ensure proper assessment before and after nebulizer treatment for 1 of 2 residents reviewed. Resident E lacked documented lung sounds, vital signs, and oxygen saturation assessments.
F 0842: The facility failed to maintain accurate and complete medical records for 4 of 11 residents reviewed, including documentation of treatments, physician consult visits, medication administration, referrals, and appointment scheduling.
Report Facts
Residents reviewed for physician appointments: 3
Residents reviewed for respiratory care: 2
Residents reviewed for medical record documentation: 11
Medication administration not initialed: 5
Dates of physician orders: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator in Training | Administrator in Training | Spoke about treatment documentation and vascular consult scheduling. |
| RN 1 | Registered Nurse | Interviewed regarding scheduling of nephrologist and infectious disease appointments. |
| RN 2 | Registered Nurse | Contacted nephrologist's office to verify appointment scheduling. |
| Social Service Director | Social Service Director | Discussed referral attempts and documentation for resident transfer. |
| Wound Nurse Practitioner | Wound Nurse Practitioner | Provided recommendations for vascular consult and treatment. |
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