13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Mishawaka, IN
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
811 E 12th Street, Mishawaka, IN
(574) 259-1917
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
87
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brickyard Healthcare
Operator or chain grouping
Approved since
1974-01-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
23 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.65
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
12,134
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.75
Baseline 77.33% · Performance 60.29% · Measure score 2.75 · Achievement 0.83 · Improvement 2.75
Adjusted total nurse staffing
0
Baseline 2.91 hours · Performance 2.94 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 13.95% · Lower 95% interval 7.46% |
| Discharge to community | 55.46% |
50.57%
4.9 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 48.39% · Lower 95% interval 42.04% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 29 |
| Staff flu vaccination coverage | 11.11% |
42%
30.9 pts worse
|
Numerator 5 · Denominator 45 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
93.6%
1.3 pts worse
|
93.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.1% · Q2 91.2% · Q3 96.4% · Q4 90.4% · 4Q avg 92.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
95.4%
1.5 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.8%
2.4 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.8% · Q4 1.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.8% |
24.6%
7.8 pts better
|
11.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 20.0% · Q3 18.0% · Q4 14.6% · 4Q avg 16.8% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.6%
0.1 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 6.1% · Q3 0.0% · Q4 4.4% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
23.5%
5.4 pts better
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 16.0% · Q3 18.0% · Q4 15.6% · 4Q avg 18.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
14.8%
1.4 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 17.6% · Q3 8.8% · Q4 9.7% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.8% |
13.3%
0.5 pts better
|
16.3%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 22.3% · Q3 11.6% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
11.7%
3.5 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 14.9% · Q3 8.3% · Q4 7.1% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.4%
About the same
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
24.2%
2.9 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 37.6% · Q3 25.2% · Q4 27.9% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.1%
2.2 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.9% · Q3 0.0% · Q4 1.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.0% |
81.6%
23.6 pts worse
|
81.7%
23.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.2% · Q2 76.0% · Q3 57.1% · Q4 50.0% · 4Q avg 58.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.6% |
79.0%
8.4 pts worse
|
79.7%
9.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.6% |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Resident Rights (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2026-02-03
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-02-03
Fire Safety
Implement emergency and standby power systems.
Corrected 2026-02-03
Fire Safety
Meet other general requirements that are deficient.
Corrected 2026-02-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-02-03
Fire Safety
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.
Corrected 2026-02-03
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-02-03
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-02-03
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-03
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-02-03
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-03
Fire Safety
Have an externally vented heating system.
Corrected 2026-02-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-02-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-03
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2026-02-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-01
Fire Safety
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.
Corrected 2024-11-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-01
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-01
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-11-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-15
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-15
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-12-01
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-12-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-01
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-27
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-27
Health
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.
Corrected 2025-10-27
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-10-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-10-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-27
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-27
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-10-27
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-10-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-17
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-01
Health
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.
Corrected 2024-11-01
Health
Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
Corrected 2024-11-01
Health
Assess the resident when there is a significant change in condition
Corrected 2024-11-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-01
Health
Keep all essential equipment working safely.
Corrected 2023-10-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-26
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-26
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-10-26
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2023-10-26
Health
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.
Corrected 2023-10-26
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-26
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-26
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Nearby options
South Bend, IN
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Mishawaka, IN
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
South Bend, IN
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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