Cycle 1
Health 2025-04-25 · Fire 2025-04-25
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Bloomington, IN
Brickyard Healthcare - Bloomington Care Center
1-star overall rating with 2-star inspections with $14,020 in total fines with 7 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
155 E Burks Dr, Bloomington, IN
(812) 332-4437
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
153
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brickyard Healthcare
Operator or chain grouping
Approved since
1985-06-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
23 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.77
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,909
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.56
Baseline 21.81% · Performance 19.87% · Measure score 3.56 · Achievement 3.37 · Improvement 3.56
Healthcare-associated infections
0
Baseline 8.07% · Performance 7.95% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.19
Baseline 42.10% · Performance 38.38% · Measure score 6.19 · Achievement 6.19 · Improvement 1.66
Adjusted total nurse staffing
1.62
Baseline 2.47 hours · Performance 3.17 hours · Measure score 1.62 · Achievement 0 · Improvement 1.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 12.94% · Lower 95% interval 7.32% |
| Discharge to community | 43.61% |
50.57%
7 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 30.95% · Lower 95% interval 29.61% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.12% |
95.27%
0.1 pts worse
|
Numerator 39 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 44.83% |
53.69%
8.9 pts worse
|
Numerator 13 · Denominator 29 |
| Discharge mobility score | 37.93% |
50.94%
13 pts worse
|
Numerator 11 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 7.32% |
2.29%
5 pts worse
|
Numerator 3 · Denominator 41 · Adjusted rate 6.11% |
| Healthcare-associated infections requiring hospitalization | 7.95% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 4.5% |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 129 |
| Staff flu vaccination coverage | 15.04% |
42%
27 pts worse
|
Numerator 20 · Denominator 133 |
| Discharge function score | 41.38% |
56.45%
15.1 pts worse
|
Numerator 12 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 3.45% |
25.2%
21.8 pts worse
|
Numerator 1 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.3 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.5
0.7 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
93.6%
3.2 pts worse
|
93.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 92.0% · Q3 93.2% · Q4 85.2% · 4Q avg 90.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.2% |
95.4%
5.2 pts worse
|
95.5%
5.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.8%
0.2 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.6% · Q3 4.2% · Q4 3.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
24.6%
20.8 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.9% · Q3 2.7% · Q4 6.7% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.6%
0.5 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 4.0% · Q3 4.7% · Q4 3.9% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 41.8% |
23.5%
18.3 pts worse
|
19.6%
22.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 45.5% · Q3 39.3% · Q4 35.3% · 4Q avg 41.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.7% |
14.8%
20.9 pts worse
|
16.7%
19 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 41.2% · Q3 35.4% · Q4 30.7% · 4Q avg 35.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.1% |
13.3%
2.2 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 13.1% · Q3 14.4% · Q4 9.5% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
11.7%
4.1 pts worse
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 20.8% · Q3 15.8% · Q4 5.3% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
24.2%
2.6 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 24.7% · Q3 24.0% · Q4 27.1% · 4Q avg 26.8% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.1%
0.3 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 1.9% · Q3 4.7% · Q4 2.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.6% |
81.6%
28 pts worse
|
81.7%
28.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.8% · Q2 69.4% · Q3 36.8% · Q4 23.4% · 4Q avg 53.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
10.5%
8.2 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 18.5% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.3%
2.2 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.4% · Q3 3.1% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.9% |
79.0%
38.1 pts worse
|
79.7%
38.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
22.4%
7.7 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 33.3% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-24 · Fire 2024-06-24
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-24 · Fire 2023-07-24
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-04-25
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-04-25
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-04-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-04-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-04-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-25
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-06-27
F · Potential for more than minimal harm
2024-06-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-06-24
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-06-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-24
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-12
B · Minimal harm
2024-06-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-12
F · Potential for more than minimal harm
2023-07-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-25
C · Minimal harm
2023-07-24
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-08-25
C · Minimal harm
2023-07-24
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-08-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-15
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-04-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-04-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-04-25
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-04-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-04-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-17
J · Immediate jeopardy
2025-04-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-01-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-07
D · Potential for more than minimal harm
2024-10-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-06-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-24
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-04-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-22
E · Potential for more than minimal harm
2023-07-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-15
Penalties and ownership
What sits behind the stars
$14,020
2025-04-03
Fine
Fine · fine $14,020
Fine
Ownership
Hendricks County Hospital
5% Or Greater Direct Ownership Interest · Organization
Engels, Erin
Corporate Director · Individual
Fenoughty, Deanna
Corporate Officer · Individual
Gentry, Mark
Corporate Director · Individual
Ggnsc Bloomington LLC
Operational/Managerial Control · Organization
Starkey, Tyler
Corporate Director · Individual
Swaby, Scott
Contracted Managing Employee · Individual
Waite, John
Corporate Director · Individual
Whicker, Timothy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Hearthstone Health Campus
Bloomington, IN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Aperion Care Monroe
Bloomington, IN
1-star overall rating with 3-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Majestic Care Of Bloomington
Bloomington, IN
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out