Cycle 1
Health 2025-11-21 · Fire 2025-11-21
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Indianapolis, IN
Brickyard Healthcare - Churchman Care Center
4-star overall rating with 3-star inspections with $25,298 in total fines with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2860 Churchman Ave, Indianapolis, IN
(317) 787-3451
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
115
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brickyard Healthcare
Operator or chain grouping
Approved since
1972-10-27
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
0.60
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.71
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,079
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.80
Baseline 67.86% · Performance 53.66% · Measure score 2.80 · Achievement 2.45 · Improvement 2.80
Adjusted total nurse staffing
0
Baseline 2.87 hours · Performance 2.76 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.23% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 26.67% · Lower 95% interval 7.73% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 112 |
| Staff flu vaccination coverage | 11.29% |
42%
30.7 pts worse
|
Numerator 14 · Denominator 124 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.7% |
93.6%
21.9 pts worse
|
93.4%
21.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.4% · Q2 68.8% · Q3 68.1% · Q4 70.8% · 4Q avg 71.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 63.5% |
95.4%
31.9 pts worse
|
95.5%
32 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 63.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.8%
3.8 pts better
|
3.3%
3.3 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 who have depressive symptoms | 82.6% |
24.6%
58 pts worse
|
11.4%
71.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.6% · Q2 76.9% · Q3 90.5% · Q4 84.2% · 4Q avg 82.6% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
5.6%
2.1 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 7.8% · Q3 1.4% · Q4 7.8% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.6% |
23.5%
10.1 pts worse
|
19.6%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 34.4% · Q3 32.9% · Q4 37.5% · 4Q avg 33.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.7% |
14.8%
19.9 pts worse
|
16.7%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 30.6% · Q3 38.5% · Q4 35.5% · 4Q avg 34.7% · 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 | 4.4% |
13.3%
8.9 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 6.7% · Q4 5.6% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.0% |
11.7%
9.7 pts better
|
14.9%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 1.7% · Q3 1.4% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.4%
About the same
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 26.9% |
24.2%
2.7 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 23.0% · Q3 26.7% · Q4 21.8% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.1%
2.5 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 25.3% |
81.6%
56.3 pts worse
|
81.7%
56.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 11.9% · Q3 36.4% · Q4 47.4% · 4Q avg 25.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.3%
0.1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 21.1% |
79.0%
57.9 pts worse
|
79.7%
58.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 21.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-22 · Fire 2024-10-22
12 health deficiencies
Top issue: Infection Control (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-12-01 · Fire 2023-12-01
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-11-21
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 2026-02-28
E · Potential for more than minimal harm
2025-11-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-02-28
E · Potential for more than minimal harm
2025-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-28
E · Potential for more than minimal harm
2025-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-28
E · Potential for more than minimal harm
2025-11-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-02-28
E · Potential for more than minimal harm
2025-11-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2026-02-28
E · Potential for more than minimal harm
2025-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-28
C · Minimal harm
2025-11-21
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2026-02-28
F · Potential for more than minimal harm
2024-10-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-10-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-22
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-22
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 2024-12-02
D · Potential for more than minimal harm
2024-10-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-02
F · Potential for more than minimal harm
2023-12-01
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-20
F · Potential for more than minimal harm
2023-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-20
F · Potential for more than minimal harm
2023-12-01
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-01
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-01
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-01
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 2024-01-20
E · Potential for more than minimal harm
2023-12-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-01-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
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 2025-12-24
D · Potential for more than minimal harm
2025-02-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-21
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 2024-11-20
E · Potential for more than minimal harm
2024-10-22
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 2024-11-21
E · Potential for more than minimal harm
2024-10-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-22
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-22
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 2024-11-21
D · Potential for more than minimal harm
2024-10-22
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 2024-11-21
D · Potential for more than minimal harm
2024-10-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-22
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 2024-11-21
D · Potential for more than minimal harm
2024-10-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-22
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 2024-11-21
D · Potential for more than minimal harm
2024-01-31
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 2023-12-03
D · Potential for more than minimal harm
2023-12-01
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-28
J · Immediate jeopardy
2023-08-31
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 2023-08-26
J · Immediate jeopardy
2023-08-24
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 2023-08-09
G · Actual harm
2023-08-24
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-01
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 2023-04-24
Penalties and ownership
What sits behind the stars
$12,649
2023-08-24
Fine
Fine · fine $12,649
Fine
$12,649
2023-08-24
Fine
Fine · fine $12,649
Fine
Ownership
Hendricks County Hospital
5% Or Greater Direct Ownership Interest · Organization
Armstrong, Paige
Contracted Managing Employee · Individual
Engels, Erin
Corporate Officer · Individual
Fenoughty, Deanna
Corporate Officer · Individual
Gentry, Mark
Corporate Director · Individual
Indianapolis Operating LLC
Operational/Managerial Control · Organization
Starkey, Tyler
Corporate Officer · Individual
Waite, John
Corporate Officer · Individual
Whicker, Timothy
Corporate Director · Individual
Nearby options
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Fairway Village
Indianapolis, IN
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#2
Envive Of Beech Grove
Beech Grove, IN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Beech Grove Meadows
Beech Grove, IN
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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