Federal inspection record · CMS data as of October 1, 2026
Brickyard Healthcare - Twelfth Street Care Center
811 E 12th Street, Mishawaka, IN · (574) 259-1917
- Certified beds
- 87
- Residents per day
- 60
- Ownership
- For-Profit
- Chain
- Brickyard Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- January 21, 1974
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Indiana.
-
Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Indiana homes
Brickyard Healthcare - Twelfth Street Care Center carries 51 inspection points. That is fewer than 32% of Indiana's 504 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Indiana: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–9 pts
- 4★ 9–24 pts
- 3★ 24–42 pts
- 2★ 42–72 pts
- 1★ over 72 pts
Bars show every rated home in Indiana by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
28 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care8D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Resident Rights7E
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 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.
- D
Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
Resident Assessment and Care Planning4D
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Assess the resident when there is a significant change in condition
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- B
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Nutrition and Dietary3F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Environmental3F
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- C
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- F
Keep all essential equipment working safely.
Pharmacy Service1E
- 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.
Administration1D
- 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.
Infection Control1D
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspection history
2025-09-12
10 health deficiencies · 19 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2024-09-26
8 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2023-09-26
10 health deficiencies · 6 fire-safety deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 24 min of nursing staff time a day, 46 min of it from a registered nurse.
This home
3 h 24 min
Indiana average
3 h 44 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 59% of nursing staff and 50% of registered nurses left in the past year, along with 5 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine2.7 pts worse | 91.0% | 93.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine7.8 pts worse | 87.3% | 95.1% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.3 pts better | 1.5% | 3.8% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.3 pts worse | 27.8% | 25.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.6 pts worse | 7.9% | 5.3% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication11.6 pts better | 11.9% | 23.5% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3.2 pts better | 10.5% | 13.7% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened8.5 pts better | 2.6% | 11.1% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased4.4 pts better | 6.4% | 10.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.6 pts better | 0.5% | 1.1% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence9.8 pts worse | 32.2% | 22.4% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.4 pts better | 3.1% | 3.5% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine39 pts worse | 42.9% | 81.9% | 82.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.6 pts worse | 1.7% | 1.1% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine43 pts worse | 36.2% | 79.2% | 80.1% |
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Who owns and runs it
8 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Engels, Erin | Corporate Director · Individual | 0% | 44 facilities |
| Fenoughty, Deanna | Corporate Officer · Individual | 0% | 45 facilities |
| Gee, William | Contracted Managing Employee · Individual | 0% | 1 facilities |
| Gentry, Mark | Corporate Director · Individual | 0% | 45 facilities |
| Mishawaka Operating LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Starkey, Tyler | Corporate Director · Individual | 0% | 45 facilities |
| Waite, John | Corporate Director · Individual | 0% | 45 facilities |
| Whicker, Timothy | Corporate Director · Individual | 0% | 45 facilities |
·
Fire safety
32 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke10F
- F
Inspect, test, and maintain automatic sprinkler systems.
- 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.
- D
Install corridor and hallway doors that block smoke.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Provide properly protected cooking facilities.
Gas, Vacuum, and Electrical Systems6F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure proper usage of power strips and extension cords.
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- E
Ensure proper usage of power strips and extension cords.
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- E
Ensure proper usage of power strips and extension cords.
Egress5F
- F
Meet other general requirements that are deficient.
- 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
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.
Miscellaneous5E
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- C
Have simulated fire drills held at unexpected times.
- 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.
Emergency Preparedness3F
- F
Establish staff and initial training requirements.
- F
Conduct testing and exercise requirements.
- F
Implement emergency and standby power systems.
Services3E
- E
Have properly installed electrical wiring and gas equipment.
- E
Have an externally vented heating system.
- E
Have properly installed electrical wiring and gas equipment.
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Other homes nearby
-
Trailpoint Village
South Bend, IN · American Senior Communities
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 53 min
- Fines
- $14,069
-
Brickyard Healthcare - Fountainview Care Center
Mishawaka, IN · Brickyard Healthcare
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 16 min
- Fines
- $0
-
Cardinal Nursing And Rehabilitation Center
South Bend, IN · American Senior Communities
★★★★★- Worst citation, 3 yrs
- D
- Nursing / resident / day
- 3 h 38 min
- Fines
- $0