Brickyard Healthcare - Churchman Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 31, 2023

  Based on interview and record review, the facility failed to provide supervision to prevent an elopement for 1 of 3 residents reviewed for elopement. A resident diagnosed with schizoaffective disorder bipolar type and dementia, had a history of elopement and attempted to leave the facility 12 days prior, left the facility. The resident's whereabouts were unknown for 2 days when the resident was located by a bystander. The resident was confused and physically and verbally combative with EMS (Emergency Medical Services), had to be restrained and required inpatient psychiatric treatment. (Resident B) This deficient practice resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF600Aug 24, 2023

  Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse from a staff member related to a staff member pushing a resident to the floor after a verbal altercation, for 1 of 4 residents reviewed for abuse. A facility staff member failed to react and respond to a resident's behavior appropriately and professionally, resulting in the staff member purposefully pushing the resident to the ground. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 7/27/23 at approximately 8:00 p.m., when the facility failed to protect the resident's right to be free from physical abuse. […]

• Actual harm, isolatedF740Aug 24, 2023

  Based on interview and record review, the facility failed to develop a behavioral health care plan that included person-centered interventions to reduce or prevent intrusive, physically violent, and verbally aggressive behaviors for 1 of 4 residents reviewed for behavioral health services. This deficient practice resulted in one resident being pulled out of bed and one resident being hit repetitively. (Resident C, Resident D, Resident E) Finding includes: During an interview on 8/21/23 at 10:22 a.m., LPN 3 (Licensed Practical Nurse) indicated Resident C was aggressive with staff and other residents. If someone looked at him, Resident C would yell or ball his fist. Resident C would get physical with other residents. […]

• No harm, potential for more than minimal, patternF812Oct 22, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary manner for 2 of 2 kitchen observations. Hair was not covered. (Dietary Manager) Findings include: On 10/16/24 from 9:08 a.m. to 10:00 a.m., observed the Dietary Manager in the kitchen food preparation area where food had been prepared for the morning meal and shipment of supplies were being put away. The Dietary Manager was observed to be lacking a hair net with hair measuring approximately one forth of an inch over the entire head. On 10/16/24 from 11:45 a.m. to 12:45 p.m., the Dietary Manager was observed in the kitchen assisting with food preparation for the noon meal. The Dietary Manager was observed to be lacking a hair net. […]

• No harm, potential for more than minimal, patternF883Oct 22, 2024

  Based on interview and record review, the facility failed to have residents sign the appropriate consent or refusal forms for pneumococcal vaccinations upon admission for 4 of 5 residents reviewed for immunization records. (Resident 3, Resident 32, Resident 33, and Resident 44) Findings include: 1. On 10/16/24 at 10:45 a.m., Resident 3's clinical record was reviewed. Resident 3's diagnoses included, but were not limited to, COPD (a lung disease that makes it difficult to breathe), chronic hepatitis C (a viral infection that affects the liver), and unspecified kidney injury. On 10/17/24 at 8:30 a.m., the DON (Director of Nursing), provided a copy of Resident 3's pneumococcal vaccine consent form. […]