Brickyard Healthcare - Portage Care Center

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 19, 2023

  Based on observation, record review and interview failed to ensure a resident was free from neglect related to not being assessed and transferred to the hospital in a timely manner after a change in condition, which resulted in a delay of treatment for a resident who later expired, for 1 of 3 residents reviewed for change in condition. (Resident B) The deficient practice involving Resident B was corrected on [DATE], prior to the start of the survey, and was therefore past noncompliance. The facility investigated the resident's change of condition and then assessed all residents for change of condition, provided inservice education to all staff and audited assessment skills for licensed nurses. The nurse who did not address the change of condition was disciplined. […]

• No harm, potential for more than minimal, widespreadF812Jan 12, 2026

  Based 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. Finding includes: The initial kitchen tour was completed on 1/5/26 at 9:09 a.m. with the Dietary Manager (DM). The DM indicated the dishwasher was a high temperature dish machine. Dietary Server 1 was observed putting trays of dishes through the dishwasher. A wash cycle was observed with Dietary Server 1. There were three gauges on top of the dishwasher. During the wash cycle, the wash temperature gauge and the rinse temperature gauge did not move from 150 degrees F (Fahrenheit). […]

• No harm, potential for more than minimal, patternF684Jan 12, 2026

  Based 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)Findings include: 1. The record for Resident 10 was reviewed on 1/8/26 at 11:32 a.m. […]

• No harm, potential for more than minimal, patternF842Jan 12, 2026

  Based 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)Findings include:1. On 1/6/26 at 11:00 a.m., Resident 112 was seated in her wheelchair in her room. She had no oxygen in use. On 1/7/26 at 9:33 a.m. and 2:00 p.m., the resident was observed in her room. She was not wearing oxygen per a nasal cannula at the time. On 1/8/26 at 2:05 p.m., the resident was seated in her wheelchair and being transported back to her room. A portable oxygen tank was hanging from the back of the wheelchair. […]

• No harm, potential for more than minimal, patternF657Jul 12, 2022

  Based on record review and interview, the facility failed to ensure residents and/or their Responsible Party were invited to attend and participate in care planning conferences for 7 of 7 residents reviewed for participation in care planning. (Residents 10, 39, 84, 44, 60, 90, and 16) Findings include: 1. Interview with Resident 10 on 7/8/22 at 8:28 a.m., indicated he had not participated in any care conferences and he did not remember being invited to a care conference. The record for Resident 10 was reviewed on 7/7/22 at 2:52 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) assessment, dated 6/17/22, indicated the resident was cognitively intact for daily decision making. […]