Deficiency Records for Brickyard Healthcare - Elkhart Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Brickyard Healthcare - Elkhart Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-07-27 | 2023-09-08 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-07-27 | 2023-09-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-27 | 2023-09-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-27 | 2023-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-27 | 2023-09-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-27 | 2023-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-27 | 2023-09-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-07-27 | 2023-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-27 | 2023-09-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-27 | 2023-09-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-27 | 2023-09-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-27 | 2023-09-08 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-04-27 | 2023-04-21 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-03-02 | 2023-03-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-02 | 2023-03-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-02 | 2023-03-24 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-02 | 2023-03-24 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-02 | 2023-03-24 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-03-02 | 2023-03-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-01 | 2022-02-25 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-14 | 2022-02-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-14 | 2022-02-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-14 | 2022-02-11 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Conform to length requirements for dead end corridors. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-14 | 2021-11-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-01 | 2021-11-01 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-10-01 | 2021-11-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-01 | 2021-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-01 | 2021-11-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-01 | 2021-11-01 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2021-10-01 | 2021-11-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-10-01 | 2021-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-01 | 2021-11-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-01 | 2021-11-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-01 | 2021-11-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-01 | 2021-11-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-01 | 2021-11-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-01 | 2021-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-01 | 2021-11-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-01 | 2021-11-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-06-04 | 2021-07-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-04 | 2021-07-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-04 | 2021-07-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-04 | 2021-07-02 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-06-04 | 2021-07-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-31 | 2021-04-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-03-31 | 2021-04-30 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-02 | 2019-04-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-02 | 2019-04-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-04-02 | 2019-04-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-04-02 | 2019-04-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-02 | 2019-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-02 | 2019-04-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-02 | 2019-04-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-02 | 2019-04-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-27 | 2019-03-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-02-27 | 2019-03-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-27 | 2019-03-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-02-27 | 2019-03-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-27 | 2019-03-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-27 | 2019-03-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-02-27 | 2019-03-28 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-02-27 | 2019-03-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-27 | 2019-03-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-02-27 | 2019-03-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-02-27 | 2019-03-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-02-27 | 2019-03-28 | N |
