Federal inspection record · CMS data as of October 1, 2026
Brickyard Healthcare - Willow Springs Care Center
2002 West 86th Street, Indianapolis, IN · (317) 872-8811
- Certified beds
- 134
- Residents per day
- 58
- Ownership
- For-Profit
- Chain
- Brickyard Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- May 21, 2015
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Indiana.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Indiana homes
Brickyard Healthcare - Willow Springs Care Center carries 56 inspection points. That is fewer than 27% of Indiana's 504 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Indiana: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–9 pts
- 4★ 9–24 pts
- 3★ 24–42 pts
- 2★ 42–72 pts
- 1★ over 72 pts
Bars show every rated home in Indiana by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
40 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care12E
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
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.
- D
Provide or obtain dental services for each resident.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Resident Rights9D
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- D
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.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
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.
- D
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.
Pharmacy Service7D
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
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.
- D
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.
Resident Assessment and Care Planning6D
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure each resident receives an accurate assessment.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Nutrition and Dietary2D
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control1D
- D
Provide and implement an infection prevention and control program.
Administration1D
- D
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.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Environmental1E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspection history
2025-05-07
11 health deficiencies · 2 fire-safety deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2024-06-28
17 health deficiencies · 11 fire-safety deficiencies
Top issue: Resident Rights (6 deficiencies)
2023-03-27
12 health deficiencies · 11 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 23 min of nursing staff time a day, 55 min of it from a registered nurse.
This home
3 h 23 min
Indiana average
3 h 44 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 72% of nursing staff and 64% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine23.7 pts worse | 70.0% | 93.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine20.9 pts worse | 74.2% | 95.1% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.4 pts better | 1.4% | 3.8% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms31.1 pts worse | 56.6% | 25.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.8 pts better | 3.5% | 5.3% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.3 pts worse | 23.8% | 23.5% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication0.1 pts better | 13.6% | 13.7% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened5.4 pts better | 5.7% | 11.1% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased4.3 pts better | 6.5% | 10.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.2 pts better | 0.9% | 1.1% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence3.2 pts worse | 25.6% | 22.4% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3.3 pts worse | 6.8% | 3.5% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine44.9 pts worse | 37.0% | 81.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.7 pts better | 10.2% | 10.9% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.5 pts better | 0.6% | 1.1% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine56.5 pts worse | 22.7% | 79.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission9.5 pts worse | 31.3% | 21.8% | 23.4% |
·
Who owns and runs it
8 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Engels, Erin | Corporate Director · Individual | 0% | 44 facilities |
| Fenoughty, Deanna | Corporate Officer · Individual | 0% | 45 facilities |
| Gentry, Mark | Corporate Director · Individual | 0% | 45 facilities |
| North Willow Operating LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Patel, Sonia | Contracted Managing Employee · Individual | 0% | 1 facilities |
| Starkey, Tyler | Corporate Director · Individual | 0% | 45 facilities |
| Waite, John | Corporate Director · Individual | 0% | 45 facilities |
| Whicker, Timothy | Corporate Director · Individual | 0% | 45 facilities |
·
Fire safety
24 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke10F
- E
Install an approved automatic sprinkler system.
- E
Inspect, test, and maintain automatic sprinkler systems.
- D
Provide properly protected cooking facilities.
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Install corridor and hallway doors that block smoke.
- D
Provide properly protected cooking facilities.
- C
Have approved installation, maintenance and testing program for fire alarm systems.
Gas, Vacuum, and Electrical Systems5F
- E
Ensure proper usage of power strips and extension cords.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- E
Ensure proper usage of power strips and extension cords.
- E
Have proper medical gas storage and administration areas.
Egress4F
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F
Meet other general requirements that are deficient.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
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.
Miscellaneous3F
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Construction1E
- E
Meet other general requirements.
Services1E
- E
Install properly constructed and protected linen or trash chutes.
·
Other homes nearby
-
Spring Mill Meadows
Indianapolis, IN · American Senior Communities
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 40 min
- Fines
- $0
-
St Augustine Home For The Aged
Indianapolis, IN · Little Sisters Of The Poor
★★★★★- Worst citation, 3 yrs
- D
- Nursing / resident / day
- 9 h 22 min
- Fines
- $0
-
Harcourt Terrace Nursing And Rehabilitation
Indianapolis, IN · American Senior Communities
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 55 min
- Fines
- $0