B81

BRICKYARD HEALTHCARE - TWELFTH STREET CARE CENTER

Grade B 81/100 composite score

Government - County

CMS Star Ratings

Overall
4/5
Health Insp.
3/5
Quality
5/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

87

Ownership

Government - County

Total Fines

None

Last Survey

N/A

811 E 12TH STREET, MISHAWAKA, IN 46544
5742591917

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.65h
LPN
0.59h
CNA
2.52h
Total
3.76h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

HENDRICKS COUNTY HOSPITAL

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Sep 2012

100%

MISHAWAKA OPERATING LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Sep 2012

ENGELS, ERIN

IndividualCORPORATE DIRECTORSince Oct 2014

GENTRY, MARK

IndividualCORPORATE DIRECTORSince Jan 2022

STARKEY, TYLER

IndividualCORPORATE DIRECTORSince Aug 2020

WAITE, JOHN

IndividualCORPORATE DIRECTORSince Aug 2020

WHICKER, TIMOTHY

IndividualCORPORATE DIRECTORSince Jan 2022

FENOUGHTY, DEANNA

IndividualCORPORATE OFFICERSince Jul 2023

GEE, WILLIAM

IndividualCONTRACTED MANAGING EMPLOYEESince Mar 2023

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (39)

March 19, 2025Health3 deficiencies
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Apr 17, 2025
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 17, 2025
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Apr 17, 2025
September 26, 2024Health6 deficiencies
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Nov 1, 2024
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Nov 1, 2024
0585DMinimal harm, Isolated

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Corrected Nov 1, 2024
0637DMinimal harm, Isolated

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

Corrected Nov 1, 2024
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Nov 1, 2024
0621DMinimal harm, Isolated

Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source

Resident Rights Deficiencies

Corrected Nov 1, 2024
September 26, 2023Health9 deficiencies
0655BNo harm, Pattern

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Oct 26, 2023
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 26, 2023
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Oct 26, 2023
0740DMinimal harm, Isolated

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies

Corrected Oct 26, 2023
0807DMinimal harm, Isolated

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Nutrition and Dietary Deficiencies

Corrected Oct 26, 2023
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 26, 2023
0849DMinimal harm, Isolated

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.

Administration Deficiencies

Corrected Oct 26, 2023
0883DMinimal harm, Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Oct 26, 2023
0908FMinimal harm, Widespread

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Oct 26, 2023
May 11, 2022Health21 deficiencies
0565EMinimal harm, Pattern

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Jun 24, 2022
0567EMinimal harm, Pattern

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies

Corrected Jun 24, 2022
0578DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Jun 24, 2022
0602DMinimal harm, Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 24, 2022
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Jun 24, 2022
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 24, 2022
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 24, 2022
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Jun 24, 2022
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Jun 24, 2022
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jun 24, 2022
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Jun 24, 2022
0688DMinimal harm, Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Corrected Jun 24, 2022
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Jun 24, 2022
0732CNo harm, Widespread

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Jun 24, 2022
0740DMinimal harm, Isolated

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies

Corrected Jun 24, 2022
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Jun 24, 2022
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Jun 24, 2022
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jun 24, 2022
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jun 24, 2022
0912BNo harm, Pattern

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Environmental Deficiencies

Corrected Jun 24, 2022
0921EMinimal harm, Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Jun 24, 2022

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Frequently Asked Questions

What is the CareGrader rating for BRICKYARD HEALTHCARE - TWELFTH STREET CARE CENTER?

BRICKYARD HEALTHCARE - TWELFTH STREET CARE CENTER in MISHAWAKA, Indiana has a CareGrader grade of B (Good), with a composite score of 81.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for BRICKYARD HEALTHCARE - TWELFTH STREET CARE CENTER?

BRICKYARD HEALTHCARE - TWELFTH STREET CARE CENTER has an overall CMS star rating of 4 out of 5, a health inspection rating of 3/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does BRICKYARD HEALTHCARE - TWELFTH STREET CARE CENTER have?

BRICKYARD HEALTHCARE - TWELFTH STREET CARE CENTER has 39 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does BRICKYARD HEALTHCARE - TWELFTH STREET CARE CENTER have?

BRICKYARD HEALTHCARE - TWELFTH STREET CARE CENTER has 87 certified beds with approximately 54 current residents (62% occupancy). The facility is located at 811 E 12TH STREET, MISHAWAKA, Indiana 46544. It is a government - county facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.