Brickyard Healthcare - Brentwood Care Center

Based on observation, interview, and record review, the facility failed to ensure medications were properly dated, labeled, and not expired for 1 of 4 medication carts, and 2 of 2 medication storage rooms reviewed for medication storage. (400 Hall Medication Cart, North Hall Medication Storage Room Refrigerator, South Hall Medication Room with Refrigerator) Findings include: On 2/20/25 at 10:00 A.M., the following undated medications were observed in the 400 Hall Medication Cart: 1 Humalog Insulin pen for [Patient Name] with no open date On 2/24/25 at 9:10 A.M., the following expired medications were observed in the North Hall Medication Storage Room Refrigerator: 1 bottle of Mary's Medical Mouth Wash for [Resident Name] with an expiration date of 1/15/25 On 2/24/25 at 10:16 A.M., the following expired medications were found in the South Hall Medication Storage Room and Refrigerator: 1 bottle of 0.9% Sodium Chloride Solution for [Patient Name] with an expiration date of 10/19/24 1 bottle of 0.9% Sodium Chloride Solution for [Patient Name] with an expiration date of 1/24/25 1 vial of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services were provided according to professional standards to prevent urinary tract infections (UTI) for 1 of 2 residents reviewed with indwelling urinary catheter use. (Resident 90) Referrals to the urologist were not made, voiding trials were not completed as ordered, care plans were not updated to reflect new orders, the provider did not assess the resident in a timely manner, and infection control practices were not followed. Finding includes: On 2/20/25 at 10:40 A.M., Resident 90 was observed sitting in his wheelchair in the hallway. An indwelling catheter bag was observed hooked to the bottom of his wheelchair. The catheter bag and tubing were observed dragging on the floor. Sediment was observed in the catheter tubing. On 2/21/25 at 11:10 A.M., Resident 90's clinical record was reviewed. Diagnoses included, but were not limited to, obstructive and reflux uropathy and retention of urine. The resident was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure respiratory services were provided according to professional standards for 1 of 2 residents reviewed for hospice. (Resident 1) A resident received a different amount of oxygen than what the physician ordered. Finding includes: On 2/20/25 at 2:08 P.M., Resident 1 was observed lying in bed receiving 4 Liters (L) of oxygen via nasal cannula. At that time, Resident 1 indicated he was supposed to be receiving 2L of oxygen. On 2/21/25 at 2:53 P.M., Resident 1 was observed lying in bed receiving 4L of oxygen via nasal cannula. On 2/24/25 at 10:51 A.M., Resident 1 was observed lying in bed receiving 4L of oxygen via nasal cannula. On 2/21/24 at 2:38 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/22/24, indicated Resident 1 was cognitively intact, required substantial to maximal assistance (staff does more than half) for bed mobility and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure infection prevention standards were implemented during care provided for two random observations of residents requiring Enhanced Barrier Precautions (EBP). (Resident 1 and Resident 12) Findings include: 1. During a direct care observation on 2/24/25 at 10:51 A.M., Hospice Nurse 11 assisted in repositioning Resident 1 in bed by pulling the resident up. Hospice Nurse 11 was not wearing a gown. Resident 1's room door had a sign indicating enhanced barrier precautions should be followed and staff who perform high contact activities with Resident 1 should wear a gown and gloves. On 2/21/25 at 2:38 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, chronic kidney disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/22/24, indicated Resident 1 was cognitively intact, required substantial assistance (staff do more than half of the work) for rolling left to right, and had an indwelling catheter. Current physician orders included, but were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide proper storage of medications and personal property in 3 of 5 medication carts reviewed. Loose pills, unlabeled medications, and resident's personal property were found in medication drawers and the narcotic box of medication carts. (200 Hall, 500 Hall, Alzheimer Unit) Findings include: 1. On 1/18/24 at 8:38 A.M., the upper drawer of the tan cart on the 200 hall was observed to have the following unlabeled medications: 1 box of antihistamine lacked a name and label. 1 box of antihistamine with [patient name] lacked a label. 1 bottle of acetaminophen with [patient name] lacked a label. 2. On 1/18/24 at 8:59 A.M., the medication cart on the 500 Hall was observed to have the following medications loose in 2 drawers of the cart: 1 bottle of Flonase with [patient name] 1 bottle of Calcitonin with [patient name] 1 large pill with KCL M20 1/2 large oblong pill 1/2 white circle pill 2 ½ medium white circle pill with no numbers 1 oblong yellow pill with no numbers 1 small round peach pill with number S 1P 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature for 1 of 1 tray tested for food temperature. Finding includes: On 1/16/24 at 11:30 A.M., Resident 79 indicated the food was not hot enough. On 1/16/24 at 11:38 A.M., Resident 1 indicated the food was cold. She lived in the last room served on her hall. On 1/18/24 at 12:03 P.M., 2 Certified Nursing Aides (CNA) were observed delivering meal trays on the 500 hallway. All but 4 trays were in a large, insulated cart. The other 4 trays were on a small pushcart, not insulated. At that time, CNA 11 indicated the larger insulated cart was too small to hold all the trays for the hall. On 1/18/24 at 12:15 P.M., a test tray was obtained from the 500 hallway. Food temperatures for that meal were as follows: Goulash - 120 degrees F (Fahrenheit) Cauliflower - 105 degrees F Milk - 43 degrees F A food serving temperature policy was requested and not provided. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to store foods in accordance with professional standards and maintain the dishwasher with the proper equipment for 1 of 1 kitchens reviewed. Findings include: 1. On 1/16/24 at 10:20 A.M., a tour of the kitchen began. Two staff were present, a cook and the dishwasher. On 1/16/24 at 10:35 A.M., food packages were observed in the walk-in refrigerator labeled with a date in black marker. None of the marked dates differentiated between open date and use-by date. Outdated/expired food included: 1 angel food cake, cut, opened, in plastic wrap dated 1/5/24 1 angel food cake, in plastic wrap, not cut, no date 1 gallon pickles, opened, manufacturer's use-by date was 10/14/23 1 5-lb (pound) container cottage cheese, opened, manufacturer's expiration date was 11/23/23 1 5-lb container sour cream, opened, manufacturer's expiration date was 12/23/23 2 large trays of ground beef thawing on the bottom shelf, not dated, in plastic bags open to air 1 16-ounce container of chicken base, opened not dated. 1 bag salad mix, opened,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment was completed accurately for 1 of 1 resident reviewed for dialysis. (Resident 50) Finding includes: On 1/17/24 at 2:18 P.M., Resident 50's clinical record was reviewed. Diagnoses included, but were not limited to, muscle wasting and atrophy, legal blindness, type 2 diabetes mellitus, end stage renal disease, and long term (current) use of insulin. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 12/12/23, indicated Resident 50 had moderate cognitive impairment, received an insulin injection for 7 out of 7 days during the look back period (12/6/23 - 12/12/23), did not receive any hypoglycemic medication, had a weight loss of 5% or more in the past month or 10% or more in the past 6 months, and had a weight gain of 5% or more in the last month or 10% or more in the last 6 months. Current physician orders included, but were not limited to: Insulin Lispro (a fast-acting hypoglycemic medication) Subcutaneous Solution Pen-injector 100 unit/ml (units per milliliters)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure CNAs (Certified Nursing Aide) had a current and valid certificate to work in the facility for 1 CNA whose certificate had expired at the time of hire. (CNA 7) Finding includes: On [DATE] at 12:10 P.M., the employee records were reviewed. CNA 7 started employment at the facility on [DATE]. The facility's employee license binder lacked a record of CNA certification for CNA 7. On [DATE] at 12:54 P.M., an Indiana Professional Licensing Agency search indicated CNA 7's CNA certificate expired [DATE]. On [DATE] at 2:38 P.M., the Administrator provided a valid CNA certificate for CNA 7 with a renewal date of [DATE]. On [DATE] at 11:12 A.M., the Administrator indicated she was aware CNA 7 had been hired with an expired license, but assumed it had been taken care of and was unaware it hadn't been renewed until it was brought to her attention on [DATE]. On [DATE] at 9:16 A.M., the Administrator provided a current License Verification policy, dated 2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure proper interventions were in place for monitoring symptoms, side effects, and behaviors of medications used for dementia for 1 of 3 residents reviewed for dementia care. (Resident 80) Finding includes: On 1/17/24 at 2:38 P.M., Resident 80's clinical record was reviewed. Diagnosis included, but was not limited to, Alzheimer's Disease with late onset and unspecified dementia. The current quarterly MDS (Minimum Data Set) assessment, dated 12/24/23, indicated the resident was cognitively intact and needed limited assistance with mobility, transfers, and eating. The MDS assessment also indicated the resident received an antipsychotic medication during the 7 day lookback period. Current physician orders included but were not limited to: Rexulti (an antipsychotic medication) - 1 mg (milligram) in the evening for dementia with behaviors, dated 11/6/23. The clinical record lacked an order, care plan, and documentation for monitoring antipsychotic side effects and behaviors. The current MAR (Medication Administration Record)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who display or are diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents reviewed for dementia. Family consent was given for a resident with a diagnoses of dementia to be in a consensual sexual relationship. ( Resident B) Finding includes: On 10/2/23 at 10:10 a.m., Resident B was observed lying awake in bed. Resident B did not answer questions appropriately and was not interviewable. On 10/2/23 at 11:12 a.m., Resident B's clinical record was reviewed. Resident B had diagnoses that included, but were not limited to, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, mood disturbance, anxiety, cognitive communication deficit, unspecified psychosis not related to a substance or known physiological condition, major depressive disorder,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained to mitigate the spread of COVID-19 for 6 of 8 observations. Staff were observed to enter rooms that required COVID- 19 transmission based precautions without the proper PPE (Personal Protective Equipment) procedures. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: On 9/12/23 at 8:44 a.m., CNA 1 was observed to don a gown, gloves, N95 mask, face shield, and enter room [ROOM NUMBER]. CNA 1's gown was observed to not be tied at the neck and the N95 mask was placed over a surgical mask before entering the room. CNA 1 was observed exiting the room with a surgical mask on. room [ROOM NUMBER] had signage on the door indicating the room required COVID-19 transmission based precautions. On 9/12/23 at 8:58 a.m., CNA 1 was observed to don a gown, gloves, N95 mask, face shield, and enter room [ROOM NUMBER]. CNA 1's gown was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.