Brickyard Healthcare - Brandywine Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 14, 2022

  Based on interview and record review, the facility failed to ensure supervision when a resident, requiring supervision with one staff person for eating, was observed placing an entire piece of garlic bread in his mouth, which later resulted in blue lips and gasping for air, followed by abdominal thrusts, cardiopulmonary resuscitation (CPR), and ultimately the death of Resident B for 1 of 3 residents reviewed for dining assistance. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when a resident was observed placing an entire piece of garlic bread into his mouth. After ,d+[DATE] minutes had passed, he was then observed with blue lips and gasping for air. […]

• Immediate jeopardy, isolatedF803Jul 14, 2022

  Based on interview and record review, the facility failed to ensure a resident received their diet as ordered that resulted in choking, administration of the [MEDICATION(S)] maneuver, administration of cardiopulmonary resuscitation (CPR), and ultimately in the death of Resident B for 1 of 3 residents reviewed for dietary needs. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when a resident with a history of putting large amounts of food into his mouth at a time, put an entire piece of garlic bread in his mouth, that was not consistent with his diet orders, that resulted in choking, administration of the [MEDICATION(S)] maneuver, administration of CPR, and Resident B passing away on [DATE]. […]

• Actual harm, isolatedF744Nov 13, 2025

  Based on observation, interview, and record review, the facility failed to timely develop individualized plans of care for residents who displayed behaviors, document behavioral incidents in the clinical record, document effectiveness of interventions used to manage behaviors, review behaviors with an interdisciplinary team, and provide adequate supervision resulting in increased behaviors and resident-to-resident altercations. (Resident C, D, G, H, and J)Findings include: 1a. The clinical record for Resident D was reviewed on 11/12/25 at 11: 15 a.m. […]

• Actual harm, isolatedF600Aug 21, 2024

  Based on interview, observation, and record review, the facility failed to prevent three events of resident-to-resident physical abuse perpetrated by Resident B for 3 of 5 resident reviewed for abuse. This deficient practice resulted in Resident D, Resident G, and Resident E being physically assaulted by Resident B and experiencing negative psychosocial outcomes. Findings include: The facility incident reports, dated from 7/8/2024 through 8/10/2024, indicated Resident B perpetrated resident-to-resident physical abuse on three events as follows: Event 1: 7/8/2024 indicated an event of resident-to-resident physical abuse perpetrated by Resident B occurred at 5:10 p.m. when Resident B was sitting in a wheelchair in the threshold of a staff member's door. […]

• Actual harm, isolatedF684Oct 25, 2022

  Based on interview and record review, the facility failed to follow up with a resident's change in condition (Resident B) in regard to loose stools for excessive duration that resulted in hospitalization , [CONDITION(S)], and shock for 1 of 3 residents reviewed for change in condition. Findings include: The clinical record for Resident B was reviewed on 10/21/22 at 12:46 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Minimum Data Set (MDS) assessment, dated 5/16/22, indicated Resident B was cognitively impaired, required extensive assistance with 2 staff for bed mobility and transfers, extensive assistance with 1 staff for eating, and was always incontinent of bowel. […]