Brickyard Healthcare - Elkhart Care Center

In the surveyor’s words

From the most serious findings on record at Brickyard Healthcare - Elkhart Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Mar 2, 2023

  Based on interview and record review, the facility failed to ensure a resident who was admitted with pressure ulcers received appropriate treatment/services to prevent deterioration, infection and additional wounds. (Resident J) The immediate jeopardy began on 1/10/23 when the facility did not follow the Nurse Practitioner treatment orders to prevent the deterioration of the of pressure ulcers, a hospitalization , additional wounds discovered in emergency room and passed away 2 days later due to complications, one being pressure ulcers. The Administrator, the Director of Nursing (DON), an Assistant Director of Nursing (ADON), a Regional Nurse and a Registered Nurse (RN) were notified of the immediate jeopardy, at 4:28 P.M. on 2/28/23. […]

• Immediate jeopardy, isolatedF690Mar 2, 2023

  Based on interview and record review, the facility failed to ensure thorough assessments and care was provided for the use of a Foley catheter in 1 of 3 residents. And failed to identify a change in condition which resulted in sepsis and death . (Resident J) The Immediate jeopardy began on [DATE] when the resident entered the facility with a Foley catheter, and the facility did not document catheter care for 8 days and had no documentation of resident's output from the catheter. The resident was sent to a local hospital where he was diagnosed with Sepsis and an Urinary Tract Infection due to the Foley catheter. The resident deceased on [DATE]. […]

• Actual harm, isolatedF804May 1, 2026

  Based on observation, interview and record review, the facility failed to ensure hot coffee was served at a safe temperature for 1 of 3 residents reviewed for accidents, resulting in a resident sustaining skin burns when coffee was spilled on her lap, (Resident B). This deficient practice had the potential to affect 112 of 112 residents who could choose to receive daily hot coffee from the facility kitchen.Findings include:On 4/29/26 at 9:56 A.M., Resident B's clinical record was reviewed. […]

• Actual harm, isolatedF805Apr 27, 2023

  Based on record review and interview, the facility failed to provide the appropriate supervision and the appropriate textured diet for 1 of 3 residents reviewed for mechanically altered diets that resulted death. (Resident B) Finding includes: A record review was completed for Resident B on [DATE] at 4:33 P.M. Diagnoses included, but were not limited to: Parkinson's disease, hemiplegia, dementia, and atrial fibrillation. A Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident B had severe cognitive impairment. He was able to be understood and understand others. He required meal set-up with supervision for eating. […]

• No harm, potential for more than minimal, widespreadF804Oct 4, 2024

  Based on observation, record review and interview, the facility failed to ensure food was served at palatable temperatures in 1 of 1 kitchens observed (Main Kitchen). This deficient practice potentially affected 110 of 120 residents who consumed food from the main kitchen. Finding includes: During a meal observation with [NAME] 1 in the Main Kitchen, on 10/1/24 at 12:00 P.M., the food temperatures of hot foods on the steam table were a follows: pureed corn 105 F (Fahrenheit), cream corn 123 F, pureed beef 118 F, beef gravy 128 F, pepper steak 123 F, whole corn 141 and sweet potato 140 During observation of room trays on the 500 hall, conducted on 10/1/24 at 12:37 P.M., meals were transported to the unit, from the kitchen on metal covered, noninsulated carts. […]