Brickyard Healthcare - Portage Care Center

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments of a resident's vascular wound were timely and accurate for 1 of 3 residents reviewed for wounds. (Resident H) The facility also failed to ensure Physician's Orders were followed related to insulin administration and blood sugar monitoring, for 3 of 3 residents reviewed for insulin administration and blood sugars. (Residents H, F, and J)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary kitchen related to the dishwasher not reaching the required temperature for a high temperature dish machine. This had the potential to affect 149 residents who received meals from the Main Kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure blood pressure medications and insulin were held according to parameters for 3 of 7 residents reviewed for unnecessary medications. The facility also failed to ensure TED hose (compression stockings) were applied as ordered for 1 of 1 resident reviewed for TED hose and areas of bruising were assessed and monitored for 3 of 4 residents reviewed for non-pressure related skin conditions. (Residents 10, 64, 75, 126, 17, 4, and 114)

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain clinical records that were complete and accurately documented related to clarification of oxygen orders and incorrect documentation of obtaining blood pressure readings on a restricted arm for 4 of 34 records reviewed. (Residents 112, 161, 92, and 2)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown while in bed during the day for 1 of 1 resident reviewed for dignity. (Resident 75)

Inspectors wroteBased on record review and interview, the facility failed to ensure referrals from the optometrist were carried out and appointments were made for 1 of 1 resident reviewed for hearing and vision. (Resident 9)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was transferred properly in a mechanical lift and a floor mat was in place for a resident with a history of falls for 2 of 8 residents reviewed for accidents. (Residents B and C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure bolus tube feeding administration as well as gastrostomy tube (a tube inserted directly into the stomach for nutrition) site care was completed as ordered for 2 of 2 residents reviewed for tube feeding. (Residents 75 and 13)

Inspectors wroteBased on record review and interview, the facility failed to document PICC line (a long-term use IV line) measurements as ordered for 1 of 2 residents reviewed with a PICC line. (Resident 161)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was flowing at the correct rate per minute for 1 of 1 resident reviewed for oxygen. (Resident 14)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided with medically related social services, related to the lack of documentation and follow up of an abuse allegation, missing cell phone, and a referral sent to another facility for 2 of 2 residents reviewed for Social Services. (Residents E and D)

Inspectors wroteBased on record review and interview, the facility failed to ensure insulin was administered as ordered and blood sugars were monitored for 1 of 5 residents reviewed for unnecessary medications. (Resident 4)Finding incudes:The record for Resident 4 was reviewed on 1/8/26 at 11:02 a.m. Diagnoses included, but were not limited to type 2 diabetes. The 11/12/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making and received insulin. The Care Plan, revised on 11/3/25, indicated the resident had diabetes mellitus. The approaches were to check the resident's blood sugar as ordered by the physician. A Physician's Order, dated 11/5/25, indicated Insulin Glargine (a long acting insulin) inject 15 units subcutaneously (sq) every morning and at bedtime and to hold if the blood sugar was less than 100. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure anti-seizure medications were available and dispensed according to physician's orders for 1 of 3 residents reviewed for seizure medication administration. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure medical appointments were completed in a timely manner for 1 of 1 resident reviewed for a medical referral. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services to promote healing related to offloading heels when in bed for 1 of 5 residents reviewed for pressure ulcers. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a call light was in reach and preventative fall measures were in use for residents who were identified as a fall risk for 2 of 5 residents reviewed for falls. (Residents C and D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Foley catheter bags and tubing were kept off of the floor for 1 of 1 resident reviewed for catheters. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate for 1 of 2 residents reviewed for respiratory care. (Resident 90)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to not sanitizing and disinfecting multiple resident use equipment for a random observation during medication pass. (Residents 71 and 53)

Inspectors wroteBased on record review and interview, the facility failed to ensure resident records were complete and accurate related to a lack of documentation regarding edema and laboratory testing for 1 of 3 residents reviewed for edema. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those specific to properly prevent and/or contain COVID-19, related to not having current outbreak status information visibly posted or passive screening completed for visitors during an outbreak. This had the potential to affect all 134 residents in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a self-medication administration assessment was completed for a resident with medication at the bedside for 1 of 1 residents reviewed for self-administration of medication. (Resident 45)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with ADL's (activities of daily living) related to nail care for 1 of 7 residents reviewed for ADL's. (Resident 118)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure palm protectors were in place as ordered for 1 of 1 residents reviewed for limited range of motion (ROM). (Resident 231)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an indwelling foley (urinary) catheter was placed below the level of the bladder and not on the floor for 3 of 3 residents reviewed for catheters. (Residents 118, 83, and 102)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received the correct diet for double portions and a fluid restriction was monitored for 2 of 3 residents reviewed for nutrition. (Residents 87 and 83)

Inspectors wrote3. On 9/20/23 at 2:22 p.m., QMA 1 was observed preparing to administer a medication through Resident 57's peg tube. QMA 1 washed her hands with soap and water and donned clean gloves to both hands. She checked for placement of the peg tube and for any residual. She attached a piston syringe to the peg tube and administered 15 ml (milliliters) of water. She then opened a package of duloxetine (antidepressant medication) and emptied it with 5 ml of water into a medicine cup. She stirred the mixture with the piston syringe and administered the medication through the peg tub. After administering the medication, she flushed the tubing with 15 ml of water. Interview with LPN 1 on 9/20/23 at 3:30 p.m., indicated QMA 1 was busy remembering the policy and didn't read the flush order correctly. The record for Resident 57 was reviewed on 9/21/23 at 10:45 a.m. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide proper respiratory care and services related to oxygen at the correct flow rate for 1 of 2 residents reviewed for oxygen. (Resident 69)

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary and safe environment related to marred and gouged walls, rusted ceiling vents, and a broken heat register control on 1 of 3 units observed. (100 unit)