Cycle 1
Health 2025-02-25 · Fire 2025-02-25
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Evansville, IN
Brickyard Healthcare - Brentwood Care Center
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
30 E Chandler Ave, Evansville, IN
(812) 423-6019
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brickyard Healthcare
Operator or chain grouping
Approved since
1985-02-06
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
0.74
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,190
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.7
Composite VBP score used to determine payment impact.
Payment multiplier
0.9879
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.23
Baseline 22.54% · Performance 20.48% · Measure score 3.23 · Achievement 2.05 · Improvement 3.23
Healthcare-associated infections
3.72
Baseline 6.34% · Performance 6.72% · Measure score 3.72 · Achievement 3.72 · Improvement 0
Total nurse turnover
5.49
Baseline 53.01% · Performance 41.25% · Measure score 5.49 · Achievement 5.49 · Improvement 3.68
Adjusted total nurse staffing
1.04
Baseline 3.01 hours · Performance 3.37 hours · Measure score 1.04 · Achievement 1.04 · Improvement 0.82
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.52% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 11.11% · Lower 95% interval 6.78% |
| Discharge to community | 37.46% |
50.57%
13.1 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 25% · Lower 95% interval 24.63% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 47 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 54.84% |
53.69%
1.2 pts better
|
Numerator 17 · Denominator 31 |
| Discharge mobility score | 58.06% |
50.94%
7.1 pts better
|
Numerator 18 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 4.26% |
2.29%
2 pts worse
|
Numerator 2 · Denominator 47 · Adjusted rate 4% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | 6.85% |
42%
35.1 pts worse
|
Numerator 10 · Denominator 146 |
| Discharge function score | 58.06% |
56.45%
1.6 pts better
|
Numerator 18 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.62% |
25.2%
9.4 pts better
|
Numerator 9 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.1 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.5 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
93.6%
1.7 pts worse
|
93.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.8% · Q2 92.1% · Q3 98.9% · Q4 96.6% · 4Q avg 91.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.8%
0.5 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.4% · Q3 2.2% · Q4 5.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.5% |
24.6%
18.1 pts better
|
11.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 7.2% · Q3 6.2% · Q4 3.8% · 4Q avg 6.5% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.6%
3.1 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.2% · Q3 3.7% · Q4 3.8% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.3% |
23.5%
8.8 pts worse
|
19.6%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 29.3% · Q3 30.9% · Q4 37.2% · 4Q avg 32.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.8% |
14.8%
14 pts worse
|
16.7%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 30.4% · Q3 27.3% · Q4 29.1% · 4Q avg 28.8% · 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 | 14.4% |
13.3%
1.1 pts worse
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 15.9% · Q3 17.6% · Q4 14.9% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
11.7%
2.2 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 15.2% · Q3 8.9% · Q4 7.9% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.2%
0.3 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
24.2%
2 pts better
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 12.8% · Q3 25.4% · Q4 22.3% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.1%
0.2 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.7% · Q3 3.4% · Q4 1.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.5% |
81.6%
5.9 pts better
|
81.7%
5.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.4% · Q2 87.3% · Q3 95.7% · Q4 91.7% · 4Q avg 87.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
10.5%
4.9 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 6.5% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.3%
0.8 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 5.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
79.0%
10.7 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
22.4%
7.8 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 35.5% · Expected 28.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-23 · Fire 2024-01-23
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-03-08 · Fire 2022-03-08
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-25
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-02-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-02-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-02-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-02-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-02-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-02-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-07
E · Potential for more than minimal harm
2025-02-25
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-05-07
E · Potential for more than minimal harm
2025-02-25
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 2025-05-07
E · Potential for more than minimal harm
2025-02-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-07
E · Potential for more than minimal harm
2025-02-25
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 2025-05-07
E · Potential for more than minimal harm
2025-02-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-07
E · Potential for more than minimal harm
2025-02-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-07
E · Potential for more than minimal harm
2025-02-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-07
E · Potential for more than minimal harm
2025-02-25
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-05-07
F · Potential for more than minimal harm
2024-01-23
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-02
F · Potential for more than minimal harm
2024-01-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-02
F · Potential for more than minimal harm
2024-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-02
F · Potential for more than minimal harm
2024-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-02
F · Potential for more than minimal harm
2024-01-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-02
F · Potential for more than minimal harm
2024-01-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-02
E · Potential for more than minimal harm
2024-01-23
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 2024-03-02
E · Potential for more than minimal harm
2024-01-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-02
E · Potential for more than minimal harm
2024-01-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-02
F · Potential for more than minimal harm
2022-03-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-04-21
E · Potential for more than minimal harm
2022-03-08
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 2022-04-21
E · Potential for more than minimal harm
2022-03-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-04-21
E · Potential for more than minimal harm
2022-03-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-21
E · Potential for more than minimal harm
2022-03-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-21
E · Potential for more than minimal harm
2022-03-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-04-21
C · Minimal harm
2022-03-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-04-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-25
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-26
E · Potential for more than minimal harm
2024-01-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-24
E · Potential for more than minimal harm
2024-01-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-24
E · Potential for more than minimal harm
2024-01-23
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 2024-01-24
D · Potential for more than minimal harm
2024-01-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-24
D · Potential for more than minimal harm
2024-01-23
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2024-01-24
D · Potential for more than minimal harm
2024-01-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-24
C · Minimal harm
2024-01-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-24
D · Potential for more than minimal harm
2023-10-03
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-03-23
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-03-14
E · Potential for more than minimal harm
2022-03-08
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 2022-03-09
E · Potential for more than minimal harm
2022-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-15
C · Minimal harm
2022-03-08
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2022-03-09
Penalties and ownership
What sits behind the stars
Ownership
Hendricks County Hospital
5% Or Greater Direct Ownership Interest · Organization
Brown, Shelley
Contracted Managing Employee · Individual
Engels, Erin
Corporate Director · Individual
Fenoughty, Deanna
Corporate Officer · Individual
Gentry, Mark
Corporate Director · Individual
Ggnsc Evansville Brentwood LLC
Operational/Managerial Control · Organization
Starkey, Tyler
Corporate Director · Individual
Waite, John
Corporate Director · Individual
Whicker, Timothy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Aperion Care Lincoln
Evansville, IN
1-star overall rating with 1-star inspections with Special Focus status with $10,224 in total fines with 30 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Columbia Healthcare Center
Evansville, IN
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Brickyard Healthcare - Woodbridge Care Center
Evansville, IN
3-star overall rating with 3-star inspections with 3 recent health deficiencies
Jump out