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Brickyard Healthcare - Willow Springs Care Center

2002 West 86Th Street, Indianapolis, IN 46260 · 3178728811 · 134 certified beds

Overall★★☆☆☆ 2/5
Health inspections★★☆☆☆ 2/5
Staffing★★☆☆☆ 2/5
Quality measures★★★☆☆ 3/5

Ownership group

Per CMS filings, this facility is affiliated with Brickyard Healthcare, a group operating 23 facilities in 1 states. Group record: average rating 2.7/5, 3 abuse citation icons, 0 facilities on the Special Focus list, $149,513 in federal fines. This facility rates below its group average (2.7/5).

See all 23 facilities in this group →

Staffing (hours per resident per day)

Total nurse staffing: 3.60 (Indiana median: 3.55). RN hours: 0.89. Weekend total: 3.00. Nursing staff turnover: 71%.

Inspection deficiencies

All-time on record: 40 deficiency citations. Below: citations from 2023 onward (severity letters explained in methodology).

Survey dateDeficiencySev.TypeStatus
2025-07-23Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Dcomplaintcorrected 2025-08-14
2025-07-23Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Dcomplaintcorrected 2025-08-14
2025-07-23Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Dcomplaintcorrected 2025-08-14
2025-05-07Reasonably accommodate the needs and preferences of each resident. DHealthcorrected 2025-06-06
2025-05-07Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Dcomplaintcorrected 2025-06-06
2025-05-07Ensure each resident receives an accurate assessment. DHealthcorrected 2025-06-06
2025-05-07Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. DHealthcorrected 2025-06-06
2025-05-07Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. DHealthcorrected 2025-06-06
2025-05-07Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. DHealthcorrected 2025-06-06
2025-05-07Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. DHealthcorrected 2025-06-06
2025-05-07Ensure each resident’s drug regimen must be free from unnecessary drugs. DHealthcorrected 2025-06-06
2025-05-07Ensure 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. DHealthcorrected 2025-06-06
2025-05-07Provide and implement an infection prevention and control program. DHealthcorrected 2025-06-06
2024-06-28Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. DHealthcorrected 2024-07-26
2024-06-28Honor 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. DHealthcorrected 2024-07-26
2024-06-28Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. DHealthcorrected 2024-07-26
2024-06-28Notify 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. DHealthcorrected 2024-07-26
2024-06-28Provide appropriate treatment and care according to orders, resident’s preferences and goals. DHealthcorrected 2024-07-26
2024-06-28Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. DHealthcorrected 2024-07-26
2024-06-28Provide safe and appropriate respiratory care for a resident when needed. DHealthcorrected 2024-07-26
2024-06-28Try 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. DHealthcorrected 2024-07-26
2024-06-28Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. DHealthcorrected 2024-07-26
2024-06-28Ensure 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. DHealthcorrected 2024-07-26
2024-06-28Provide or obtain dental services for each resident. DHealthcorrected 2024-07-26
2024-06-28Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Dcomplaintcorrected 2024-07-26
2024-06-28Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. DHealthcorrected 2024-07-26
2024-06-28Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. DHealthcorrected 2024-07-26
2024-03-14Honor 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. Dcomplaintcorrected 2024-04-05
2024-03-14Provide appropriate treatment and care according to orders, resident’s preferences and goals. Dcomplaintcorrected 2024-04-05
2024-03-14Provide safe and appropriate respiratory care for a resident when needed. Dcomplaintcorrected 2024-04-05
2024-02-13Protect each resident from the wrongful use of the resident's belongings or money. Dcomplaintcorrected 2024-01-30
2024-02-13Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Dcomplaintcorrected 2024-04-05
2024-01-26Provide appropriate treatment and care according to orders, resident’s preferences and goals. Dcomplaintcorrected 2024-04-05
2023-08-31Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Dcomplaintcorrected 2023-09-21
2023-03-27Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. EHealthcorrected 2023-04-24
2023-03-27Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. EHealthcorrected 2023-04-24
2023-03-27Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. DHealthcorrected 2023-04-24
2023-03-27Provide safe and appropriate respiratory care for a resident when needed. DHealthcorrected 2023-04-24
2023-03-27Ensure 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. DHealthcorrected 2023-04-24
2023-03-27Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. DHealthcorrected 2023-04-24

Federal penalties

No federal fines or payment denials on record.

Ownership & control records (CMS filings)

NameRoleType%Since
ENGELS, ERINCorporate DirectorIndividualNOT APPLICABLEsince 10/25/2014
GENTRY, MARKCorporate DirectorIndividualNOT APPLICABLEsince 01/12/2022
STARKEY, TYLERCorporate DirectorIndividualNOT APPLICABLEsince 08/01/2020
WAITE, JOHNCorporate DirectorIndividualNOT APPLICABLEsince 08/01/2020
WHICKER, TIMOTHYCorporate DirectorIndividualNOT APPLICABLEsince 01/12/2022
FENOUGHTY, DEANNACorporate OfficerIndividualNOT APPLICABLEsince 07/10/2023
NORTH WILLOW OPERATING LLCOperational/Managerial ControlOrganizationNOT APPLICABLEsince 04/10/2015

Compare nearby (Marion County)

Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 155834. Corrections: data@carerecords.org.