Brickyard Healthcare - Golden Rule Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF610Jun 20, 2024

  Based on observation, interview and record review, the facility failed to initiate an investigation into an allegation of sexual abuse identified by a nurse and ensure adequate protection was provided to 3 of 18 residents on the unit. (Residents 49, 50, 56, and 74) The immediate jeopardy began on 6/6/24, when 2 residents' clinical records indicated allegations of sexual abuse. The Administrator, Director of Nursing, Area [NAME] President, [NAME] President of Risk and Regulatory Compliance, and Regional Director of Clinical Operations were notified of the immediate jeopardy on 6/18/24 at 3:23 p.m. […]

• Actual harm, isolatedF600Feb 4, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were free from mental/verbal abuse and threats of seclusion resulting in fear, intimidation, and mental anguish for 2 of 6 residents reviewed for abuse (Resident B and Resident C). Using the reasonable person concept, it is likely this would lead to fear, confusion, anxiety, and intimidation for Resident B and Resident C.Findings include:1. Review of the clinical record of Resident B on 2/2/26 at 10:55 a.m., indicated the resident's diagnoses included, but were not limited to, bipolar disorder (a chronic mental health condition), anxiety, paranoid schizophrenia (a mental health condition characterized by intense, irrational delusions), dementia (a decline in mental abilities), and repeated falls. […]

• Actual harm, isolatedF742Feb 4, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident with a major mental illness was treated appropriately and failed to implement individualized interventions resulting in a physical/mental altercation between a staff member and the residents for 1 of 6 residents reviewed for mental/psychosocial services. (Resident B). Using the reasonable person concept, the resident would likely have psychological harm of chronic or recurrent fear and anxiety from how RN 5 handled the interactions with Resident B. […]

• Actual harm, isolatedF600Jun 20, 2024

  Based on observation, interview and record review, the facility failed to ensure residents were free from sexual abuse on the Alzheimer's Care Unit of the facility for 3 of 5 residents reviewed for abuse. (Residents 50, 56, and 74) Findings include: 1. The clinical record for Resident 50 was reviewed on 6/17/24 at 1:10 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and insomnia. The 5/15/24 Quarterly MDS (Minimum Data Set) assessment indicated the BIMS (brief interview for mental status) was not conducted, as she was rarely/never understood. The staff assessment for mental status indicated she had short and long-term memory problems. She did not know the current season or that she was in a nursing home. […]

• Actual harm, isolatedF740Oct 5, 2022

  Based on interview and record review, the facility failed to ensure that a resident received behavioral health services and initiation of psychiatric follow-up per the plan of care that resulted in Resident B experiencing increased depression, anxiety, paranoia, and ultimately being hospitalized in an inpatient psychiatric unit related to having suicidal and homicidal ideations for 1 of 3 residents reviewed for behavioral health. (Resident B) Findings include: The clinical record for Resident B was reviewed on 10/5/22 at 12:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B was admitted to the facility on [DATE]. […]