01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-12 | 10 | 2025-09-12 | 19 |
| Cycle 2 | 2024-09-26 | 9 | 2024-09-26 | 7 |
| Cycle 3 | 2023-09-26 | 9 | 2023-09-26 | 6 |
CMS CCN 1551092026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Brickyard Healthcare - Twelfth Street Care Center
811 E 12Th Street · Mishawaka, IN 46544 · St. Joseph County
Certified beds87CMS provider file
Recent citation rows60current 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
60 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 12 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-12 · FIREE0037Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-10-272025-09-12 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2025-10-272025-09-12 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-10-272025-09-12 · 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 · 2025-10-272025-09-12 · 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 · 2025-10-272025-09-12 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-10-272025-09-12 · HEALTHF0761Severity E · pattern; 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 · 2025-10-272025-09-12 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-10-272025-09-12 · HEALTHF0912Severity C · widespread; potential for minimal harm
Environmental Deficiencies
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Correction field: Deficient, Provider has date of correction · 2025-10-272025-09-12 · HEALTHF0921Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2025-10-272025-09-12 · 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 · 2026-02-032025-09-12 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREK0223Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREK0300Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Meet other general requirements that are deficient.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREK0345Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2026-02-032025-09-12 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2026-02-0303 / 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
- GEE, WILLIAMIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 03/07/2023
- 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
- MISHAWAKA OPERATING LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2012
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 hours3.35per resident day
RN hours0.70per resident day
Weekend nurse hours3.03per resident day
Staff turnover67.6%CMS reported field
06 / LOCAL RECORDS
Open the Mishawaka ledger →