01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-07 | 11 | 2025-05-07 | 2 |
| Cycle 2 | 2024-06-28 | 17 | 2024-06-28 | 11 |
| Cycle 3 | 2023-03-27 | 13 | 2023-03-27 | 11 |
CMS CCN 1558342026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Brickyard Healthcare - Willow Springs Care Center
2002 West 86Th Street · Indianapolis, IN 46260 · Marion County
Certified beds134CMS provider file
Recent citation rows65current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
65 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 14 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-05 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Past Non-Compliance · 2025-12-08 · complaint2025-07-23 · HEALTHF0627Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Correction field: Deficient, Provider has date of correction · 2025-08-14 · complaint2025-07-23 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-08-14 · complaint2025-07-23 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-08-14 · complaint2025-05-07 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-07 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-06-06 · complaint2025-05-07 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-07 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-07 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-07 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-07 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-07 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-07 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-07 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-07 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-05-07 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-07-142024-06-28 · HEALTHF0557Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Correction field: Deficient, Provider has date of correction · 2024-07-262024-06-28 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-07-262024-06-28 · HEALTHF0623Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Correction field: Deficient, Provider has date of correction · 2024-07-262024-06-28 · HEALTHF0625Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-07-262024-06-28 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-07-262024-06-28 · HEALTHF0691Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-07-262024-06-28 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-07-262024-06-28 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-07-2603 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PATEL, SONIAIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 09/12/2022
- ENGELS, ERINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/25/2014
- GENTRY, MARKIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/12/2022
- STARKEY, TYLERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/01/2020
- WAITE, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/01/2020
- WHICKER, TIMOTHYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/12/2022
- FENOUGHTY, DEANNAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/10/2023
- NORTH WILLOW OPERATING LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/10/2015
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.60per resident day
RN hours0.89per resident day
Weekend nurse hours3.00per resident day
Staff turnover70.9%CMS reported field
06 / LOCAL RECORDS
Open the Indianapolis ledger →Other published facilities nearby
Allison Pointe Healthcare Center144 beds · CMS overall 2/583 citation rowsAlpha Home - A Waters Community86 beds · CMS overall 1/557 citation rowsAltenheim Health & Living Community87 beds · CMS overall 4/538 citation rowsAmerican Village150 beds · CMS overall 3/573 citation rowsArlington Place Health Campus84 beds · CMS overall 4/536 citation rowsBethany Village100 beds · CMS overall 2/539 citation rowsBrickyard Healthcare - Brookview Care Center136 beds · CMS overall 3/543 citation rowsBrickyard Healthcare - Churchman Care Center115 beds · CMS overall 4/547 citation rows