D67

BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER

Grade D 67/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
4/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

134

Ownership

For profit - Corporation

Total Fines

$17,131

Last Survey

N/A

2002 WEST 86TH STREET, INDIANAPOLIS, IN 46260
3178728811

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.67h
LPN
0.95h
CNA
2.08h
Total
3.70h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

HENDRICKS COUNTY HOSPITAL

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Apr 2015

100%

NORTH WILLOW OPERATING LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2015

ENGELS, ERIN

IndividualCORPORATE DIRECTORSince Oct 2014

GENTRY, MARK

IndividualCORPORATE DIRECTORSince Jan 2022

STARKEY, TYLER

IndividualCORPORATE DIRECTORSince Aug 2020

WAITE, JOHN

IndividualCORPORATE DIRECTORSince Aug 2020

WHICKER, TIMOTHY

IndividualCORPORATE DIRECTORSince Jan 2022

FENOUGHTY, DEANNA

IndividualCORPORATE OFFICERSince Jul 2023

PATEL, SONIA

IndividualCONTRACTED MANAGING EMPLOYEESince Sep 2022

Penalties & Fines (1)

$17,131total fines
DateTypeDescriptionAmount
Jun 12, 2023Fine$17,131

Health Inspection Deficiencies (43)

July 23, 2025Health3 deficiencies
0627DMinimal harm, Isolated

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Resident Rights Deficiencies

Corrected Aug 14, 2025
0628DMinimal harm, Isolated

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Rights Deficiencies

Corrected Aug 14, 2025
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 14, 2025
May 7, 2025Health10 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Jun 6, 2025
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 6, 2025
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 6, 2025
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 6, 2025
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jun 6, 2025
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jun 6, 2025
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Jun 6, 2025
0761DMinimal harm, Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Jun 6, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jun 6, 2025
0628DMinimal harm, Isolated

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Rights Deficiencies

Corrected Jun 6, 2025
June 28, 2024Health14 deficiencies
0557DMinimal harm, Isolated

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Resident Rights Deficiencies

Corrected Jul 26, 2024
0578DMinimal harm, Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Corrected Jul 26, 2024
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Jul 26, 2024
0625DMinimal harm, Isolated

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies

Corrected Jul 26, 2024
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2024
0691DMinimal harm, Isolated

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2024
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2024
0700DMinimal harm, Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2024
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Jul 26, 2024
0761DMinimal harm, Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Jul 26, 2024
0791DMinimal harm, Isolated

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2024
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 26, 2024
0849DMinimal harm, Isolated

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Administration Deficiencies

Corrected Jul 26, 2024
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jul 26, 2024
March 14, 2024Health3 deficiencies
0584DMinimal harm, Isolated

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies

Corrected Apr 5, 2024
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Apr 5, 2024
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Apr 5, 2024
February 13, 2024Health2 deficiencies
0602DMinimal harm, Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jan 30, 2024
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Apr 5, 2024
January 26, 2024Health1 deficiency
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Apr 5, 2024
August 31, 2023Health1 deficiency
0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Sep 21, 2023
June 12, 2023Health2 deficiencies1 severe
0600JImmediate jeopardy, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 26, 2023
0839DMinimal harm, Isolated

Employ staff that are licensed, certified, or registered in accordance with state laws.

Administration Deficiencies

Corrected Jun 26, 2023
March 27, 2023Health6 deficiencies
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 24, 2023
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Apr 24, 2023
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Apr 24, 2023
0761DMinimal harm, Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Apr 24, 2023
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Apr 24, 2023
0921EMinimal harm, Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Apr 24, 2023
January 10, 2023Health1 deficiency
0584EMinimal harm, Pattern

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies

Corrected Feb 10, 2023

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Frequently Asked Questions

What is the CareGrader rating for BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER?

BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER in INDIANAPOLIS, Indiana has a CareGrader grade of D (Below Average), with a composite score of 66.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER?

BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER have?

BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER has 43 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER been fined?

Yes. BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER has $17,131 in total fines from CMS enforcement actions across 1 penalty.

How many beds does BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER have?

BRICKYARD HEALTHCARE - WILLOW SPRINGS CARE CENTER has 134 certified beds with approximately 63 current residents (47% occupancy). The facility is located at 2002 WEST 86TH STREET, INDIANAPOLIS, Indiana 46260. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.