Brickyard Healthcare Brookview: Elopement Failure - IN
Nobody had.
The resident, identified in inspection records only as Resident B, was known to wander and had been flagged as an elopement risk since his admission to the facility. His family had told staff he was a flight risk. The unit he lived on was described as a secured memory care wing, the kind of place specifically designed to keep people like him from walking out. But the bathroom windows, apparently, were a different matter.
A licensed practical nurse, identified as LPN 8, went into Resident B's room after he could not be located and found a chair positioned in the bathroom, the window screen removed, the window open. That was how he had gotten out.
LPN 8 told inspectors she had never, in her time at the facility, seen a staff member open the bathroom windows. She had never seen a resident open one either. The windows had simply never come up.
Federal inspectors arrived at the facility on October 7, 2025, following two separate complaint intakes tied to the incident. What they documented was a failure that ran from the physical structure of the building straight through to the conversations that never happened at the administrative level.
The Memory Care Director told inspectors that she had spoken with Resident B's family when he was first admitted and that the family had disclosed he was an elopement risk. What the family had not told her, she said, was that he had a history of trying to leave through windows specifically. The exit-seeking behaviors he had shown early in his stay had settled down over time. He could become agitated, she acknowledged, and was not always easy to redirect. His cognition varied from one day to the next. She said she believed the bathroom windows should have been locked. She had not noticed they were not. She had not seen any of the bathroom windows on the secured unit open before the day he left through one.
After Resident B eloped, a family member, identified as FM 3, told the Memory Care Director about the family's concerns regarding the windows. That conversation happened after October 1, not before.
The Executive Director told inspectors she had not spoken with Resident B's power of attorney about the elopement risk the bathroom windows represented. She had spoken with the facility's admissions staff member and the case manager about the situation. Neither of them had spoken with the family about the windows either.
The facility's own written elopement and wandering policy, which the Executive Director provided to inspectors on October 6, described a systematic approach to identifying and managing residents at elopement risk, including evaluation and analysis of hazards, implementing interventions to reduce those hazards, and monitoring whether those interventions were working. The policy also stated that the facility was equipped with door locks and alarms to help prevent elopement.
The bathroom windows were not mentioned.
What the policy described on paper and what existed in practice on the memory care unit were two different things. Resident B's care plan addressed his elopement risk. The secured unit had door locks. But the bathroom windows, which a resident could open, remove the screen from, and climb through with the help of a chair, had no safety blocks. Nobody on staff had identified them as a hazard. Nobody had assessed whether they needed to be secured. Nobody had told his family that the windows were a potential exit.
The inspection report classifies the deficient practice as Immediate Jeopardy, the most serious level of harm designation available under federal inspection standards, meaning inspectors determined the facility's failure created a situation likely to cause serious injury or death. Immediate Jeopardy findings require facilities to act immediately or face the suspension of Medicare and Medicaid payments.
According to the inspection record, the Immediate Jeopardy period began on October 1, 2025, the day Resident B eloped. The facility was found to have corrected the deficient practice and removed the jeopardy on the same date, after implementing a response that included completing an audit of all residents and updating elopement assessments, providing education to all staff on elopement protocol, conducting elopement drills on every shift, and auditing all windows throughout the facility to determine whether safety blocks were in place. Windows found to be missing safety blocks were fitted with them.
The corrections happened the same day the Silver Alert was called. The question of whether Resident B was found, and in what condition, is not addressed in the inspection narrative.
A Silver Alert in Indiana functions similarly to an Amber Alert but for missing adults, typically elderly individuals or those with cognitive impairments who are considered vulnerable. They are issued when someone is believed to be in danger. The fact that one was called for Resident B reflects what staff understood in the moment: a man with dementia, who could become agitated and could not always be redirected, had gotten out of a secured memory care facility and no one knew where he was.
The secured unit he had been living on was presumably chosen because it offered protections that a standard floor did not. The door locks, the alarms, the staffing model for memory care, all of it exists because residents like Resident B cannot always be relied upon to stay safe on their own. The logic of a secured unit depends on the assumption that the perimeter has been examined and the gaps have been closed.
A chair in a bathroom. A screen on the floor. A window open to the outside.
Those three details, reported by LPN 8 when she went looking for a missing resident, describe exactly what a comprehensive elopement hazard assessment is supposed to prevent. The facility's own policy used the phrase "evaluation and analysis of hazards and risks." It used the phrase "implementing interventions to reduce hazards and risks." The bathroom windows were a hazard. They had not been evaluated. No intervention had been implemented. And a man who could not always be redirected found his way to one, moved a chair under it, and left.
His family had been worried enough about elopement to disclose the risk at admission. They had not known to mention windows specifically. That was the gap the Memory Care Director described to inspectors, the piece of information the family had not provided. But the family's knowledge of their relative's history does not substitute for a facility's own assessment of its physical environment. The family knew their relative. The facility was responsible for knowing its building.
After the Silver Alert, after the window audit, after the drills on every shift, the safety blocks were installed. The Immediate Jeopardy was lifted. The inspection report closes with citations.
What it does not say is where Resident B was found, or how long he was outside, or what the October air felt like that afternoon on the streets around the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brickyard Healthcare - Brookview Care Center from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
BRICKYARD HEALTHCARE - BROOKVIEW CARE CENTER in INDIANAPOLIS, IN was cited for violations during a health inspection on October 7, 2025.
His family had told staff he was a flight risk.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.