Brickyard Healthcare - Twelfth Street Care Center
811 E 12th Street, Mishawaka, IN 46544 · St. Joseph County · (574) 259-1917
87 certified beds, about 58 residents a day · For profit - Corporation · Medicare and Medicaid since 1974
Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 155109 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on September 12, 2025, inspectors cited 10 health deficiencies (the Indiana average is 7.2, the national average 9.2).
None of its 28 health citations since September 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.35 hours per resident per day, against 3.69 across Indiana and 3.86 nationally. Registered nurses accounted for 0.70 of those hours.
67.6% of nursing staff left within the year CMS measured (Indiana average 45.9%).
CMS links it to Brickyard Healthcare, an affiliated group of 23 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
909/23
609/24
303/25
1009/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
3E
2F
Potential for minimal harm
0A
1B
1C
September 12, 2025Standard inspection · 10 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to serve food at a safe temperature from 1 of 1 kitchen observed. (Main Kitchen) This had the potential to affect 55 out 55 residents who received their meals from the kitchen.
- E Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to protect a resident's right to privacy for 1 of 1 resident reviewed for resident rights. (Resident 48) The facility also failed to ensure residents' dignity was maintained related to unprofessional verbal statements made by contracted staff for 3 of 5 residents reviewed for dignity. (Residents 5, 40 and 27)
- E 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.
Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored appropriately related to opened and undated medications and failed to ensure medication carts were locked (100 hall) for 1 of 2 medication carts reviewed and medications were not stored in the pantry refrigerator for 1 of 2 medication rooms reviewed. (200 hall)
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to respect the right of a resident/resident's POA (Power of Attorney) to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers related to a WanderGuard (bracelet device which alarms at exit doors) for 1 of 1 resident reviewed for a WanderGuard. (Resident 11)
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview, observation and record review, the facility failed to notify the physician of a resident's low blood pressure for 1 of 5 residents who were reviewed for medications and treatments. (Resident 39)
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview, the facility failed to follow a physician's order for a hypotensive medication for 1 of 3 residents reviewed for medication administration. (Resident 9)
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer a resident which resulted in the resident falling for 1 of 1 resident reviewed for falls. (Resident 7)
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor nutritional status for 1 of 2 residents reviewed for nutrition. (Resident 4)
- D Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the cleanliness of a resident's personal refrigerator for 1 of 1 personal refrigerator observed. (Resident 2)
- C Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Inspectors wroteBased on observation and interview, the facility failed to provide at least 60 square feet per resident in 22 multiple occupancy resident rooms for 2 of 2 units (100 and 200). (Rooms 100, 101, 103, 104, 108, 109, 110, 111, 112, 114, 116, 118, 204, 205, 206, 207, 211, 213, 215 and 226) In addition, the facility failed to ensure 100 square feet per resident in single resident rooms was provided. (rooms [ROOM NUMBERS])
March 19, 2025Complaint inspection · 3 citations
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified in a timely manner when a resident was given a medication in the incorrect form, refused all medications for six consecutive medication passes and experienced a decline in level of consciousness, for 1 of 3 residents review for medication administration. (Resident B).
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plans related to type 2 diabetes, seizures, bipolar disorder, congestive heart failure and anxiety were in place for 1 of 3 residents reviewed for care plans, (Resident B)
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review the facility failed to ensure Physician Orders were in place for the treatment of low blood glucose and failed to ensure hypoglycemia was assessed timely for 1 of 3 residents reviewed for diabetic treatment, (Resident B).
September 26, 2024Standard inspection, Complaint inspection · 6 citations
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, record review, and interview the facility failed to notify the physician for significantly elevated blood glucose levels for 1 of 1 resident reviewed for blood glucose (Resident 45).
- D 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.
Inspectors wroteBased on observation, interview and record review, the facility failed to respond to a resident's grievance requesting services in a timely manner for 1 out of 1 residents reviewed for grievances. (Resident L)
- D Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
Inspectors wroteBased on observation, interview and record review the facility failed to provide equal access to services including specialized rehab to a resident with Medicaid payer source for 1 of 1 resident reviewed for rehab services. (Resident L)
- D Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment timely for 2 of 3 residents reviewed for Hospice services. (Residents 16 & 28)
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interview, the facility failed to complete and maintain grooming for 3 of 4 residents reviewed for activities of daily living (ADLs). (Residents 15, L and 21)
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received adequate treatment and monitoring for a pressure ulcer for 1 out of 3 reviewed for pressure ulcers. (Resident 37)
September 26, 2023Standard inspection · 9 citations
- F Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lint trap of two dryer vents were removed every two hours to prevent a fire. This deficient practice had the potential to affect 58 of 58 residents who reside in the facility.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to store and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect 58 of 58 residents who received their meals in the dining room.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to review the care plan, and include a fall intervention to the care plan for 1 of 20 resident reviewed for care plans. (Resident 29)
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nail care and shaving was provided for 2 of 7 residents reviewed for Activities of Daily Living (ADL) needs. (Resident 3 & 50)
- D Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow a Physician's order to obtain an evaluation and treatment for psychiatric [NAME] for 1 of 20 residents reviewed. (Resident 19)
- D Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure thickened liquids were at the bedside as ordered for 2 of 2 residents reviewed. (Resident 18 and 29)
- 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.
Inspectors wroteBased on observation, interview, and record review, the facility failed to review the care plan, and include the resident, or resident representative, after each assessment for 2 out of 20 residents reviewed. (Residents 32 and 29)
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure that vaccination consent forms were provided to the resident upon admission to the facility for 1 of the 5 reviewed for infection control. (Resident 18)
- B Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review, the facility failed to provide the base line care plan to the resident and resident representative within 48 hours of admission for 2 out of 2 residents reviewed for base line care plans. (Resident 3 & 35)
Fire safety inspections
32 fire safety citations on file: 19 on September 12, 2025, 7 on September 26, 2024, 6 on September 26, 2023.
Every fire safety citation32 citations
- F Establish staff and initial training requirements.
- F Conduct testing and exercise requirements.
- F Implement emergency and standby power systems.
- F Meet other general requirements that are deficient.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have generator or other power source capable of supplying service within 10 seconds.
- 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.
- E Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Provide properly protected cooking facilities.
- E Have approved installation, maintenance and testing program for fire alarm systems.
- E Properly select, install, inspect, or maintain portable fire extinguishes.
- E Have properly installed electrical wiring and gas equipment.
- E Have an externally vented heating system.
- E To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E Ensure proper usage of power strips and extension cords.
- E Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- D Install corridor and hallway doors that block smoke.
- F Inspect, test, and maintain automatic sprinkler systems.
- 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.
- E Install corridor and hallway doors that block smoke.
- E To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E Ensure proper usage of power strips and extension cords.
- E Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- C Have simulated fire drills held at unexpected times.
- F Inspect, test, and maintain automatic sprinkler systems.
- E Provide properly protected cooking facilities.
- E Have properly installed electrical wiring and gas equipment.
- E Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- E Have restrictions on the use of portable space heaters.
- E Ensure proper usage of power strips and extension cords.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Indiana | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.35 | 3.69 | 3.86 |
| Registered nurses | 0.70 | 0.67 | 0.69 |
| All nursing staff on weekends | 3.03 | 3.25 | 3.42 |
| Nurse aides | 2.17 | ||
| Licensed practical nurses | 0.48 | ||
| Nursing staff turnover (share who left in a year) | 67.6% | 45.9% | 45.8% |
| Registered nurse turnover | 60.0% | 40.3% | 42.9% |
| Administrators who left | 4 |
CMS expects 4.36 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.48 on weekdays and 3.03 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 3.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.53 in April to June 2025 to 3.35 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.35 | 0.70 | 3.48 | 3.03 | 3.7% | 0 of 90 | 58 |
| Oct to Dec 2025 | 3.59 | 0.68 | 3.85 | 2.95 | 3.6% | 0 of 92 | 57 |
| Jul to Sep 2025 | 3.78 | 0.65 | 4.01 | 3.18 | 5.9% | 0 of 92 | 55 |
| Apr to Jun 2025 | 3.53 | 0.70 | 3.71 | 3.06 | 5.5% | 0 of 91 | 57 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Indiana, Jan to Mar 2026 | 3.63 | 0.62 | 3.80 | 3.19 | 3.4% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
Official wage estimates for Indiana
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Indiana, all employers | |||
| CNAs (nursing assistants) | $18.43 | $17.80 to $21.36 | 33,640 |
| LPNs and LVNs | $31.60 | $29.35 to $35.30 | 14,480 |
| Registered nurses | $40.14 | $37.86 to $48.28 | 68,980 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Indiana | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 6.8 | 11.0 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.5 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.5 | 1.1 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.9 | 3.9 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.0 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 5.5 | 11.9 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.9 | 3.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 9.0 | 13.6 | 15.4 |
Owners and operators
Legal business name: HENDRICKS COUNTY HOSPITAL. CMS links this home to Brickyard Healthcare, a group of 23 nursing homes averaging 2.7 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Gee, William | Contracted managing employee | Individual | 03/07/2023 | |
| Engels, Erin | Corporate director | Individual | 10/25/2014 | |
| Gentry, Mark | Corporate director | Individual | 01/12/2022 | |
| Starkey, Tyler | Corporate director | Individual | 08/01/2020 | |
| Waite, John | Corporate director | Individual | 08/01/2020 | |
| Whicker, Timothy | Corporate director | Individual | 01/12/2022 | |
| Fenoughty, Deanna | Corporate officer | Individual | 07/10/2023 | |
| Mishawaka Operating LLC | Operational/managerial control | Organization | 09/01/2012 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 8 problems in this area, most recently on September 12, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 7 problems in this area, most recently on September 12, 2025: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
- When is the care plan meeting, and can family attend it?Inspectors cited 4 problems in this area, most recently on March 19, 2025: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 3 problems in this area, most recently on September 12, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.03 hours per resident per day, below the Indiana average of 3.25.
- How long has the current administrator been here?CMS counts 4 administrators who left in the period it measured.
Other nursing homes nearby
- Trailpoint Village South Bend, 2.5 mi · 4 of 5 stars · 13 citations
- Brickyard Healthcare - Fountainview Care Center Mishawaka, 3.5 mi · 2 of 5 stars · 45 citations
- Cardinal Nursing and Rehabilitation Center South Bend, 3.9 mi · 5 of 5 stars · 13 citations
- Creekside Village Mishawaka, 4 mi · 4 of 5 stars · 22 citations
- Belltower Health & Rehabilitation Center Granger, 4.4 mi · 4 of 5 stars · 22 citations
- Southfield Village South Bend, 4.5 mi · 3 of 5 stars · 21 citations
- Holy Cross Rehabilitation and Wellness South Bend, 4.6 mi · 2 of 5 stars · 26 citations
- Milton Home, the South Bend, 4.6 mi · 5 of 5 stars · 15 citations
Indiana contacts for a concern about a nursing home
These are the official offices in Indiana. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Indiana Department of Health, Division of Long-Term Care, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Indiana Long-Term Care Ombudsman Program, 800-622-4484. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Indiana Department of Health, Nursing Home Report Cards, where Indiana publishes its own records on licensed homes.
Common questions
- What is Brickyard Healthcare - Twelfth Street Care Center's Medicare star rating?
- CMS rates Brickyard Healthcare - Twelfth Street Care Center 2 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Brickyard Healthcare - Twelfth Street Care Center get at its last inspection?
- 10 health deficiencies at the standard inspection on September 12, 2025. The Indiana average is 7.2.
- Has Brickyard Healthcare - Twelfth Street Care Center been fined?
- CMS lists no fines in the last three years.
- Does Brickyard Healthcare - Twelfth Street Care Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Brickyard Healthcare - Twelfth Street Care Center?
- CMS lists 8 owners and managers, and links the home to Brickyard Healthcare. Legal business name: HENDRICKS COUNTY HOSPITAL.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.