Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brickyard Healthcare - Twelfth Street Care Center during CMS and state inspections, most recent first.
A resident with a complex medical history experienced a decline in consciousness and refused medications for several days. The facility failed to notify the physician in a timely manner after the resident was given medication in the incorrect form and continued to refuse medications. The resident was eventually sent to the hospital after the family insisted, highlighting a lapse in following the facility's notification policy.
A facility failed to develop comprehensive care plans for a resident with multiple diagnoses, including type 2 diabetes and congestive heart failure. Despite being on high-risk medications, no care plans were in place to address these conditions. The MDS nurse confirmed the absence of care plans, which should have been established upon admission and when medications were prescribed, as per facility policy.
A facility failed to have Physician Orders for hypoglycemia management for a diabetic resident, leading to a critical low blood glucose event. The resident, with a history of multiple health issues, was found unresponsive and later diagnosed with hypoglycemia at the hospital. Staff interviews revealed a lack of timely assessment and monitoring of the resident's blood sugar levels, despite facility policy requirements.
A resident with Type 2 diabetes had multiple instances of elevated blood glucose levels exceeding 400 mg/dL, but the facility failed to notify the physician as required by the physician's order. Despite the facility's policy on notifying changes, there was no documentation in the nursing progress notes or triage binders indicating that the physician or Nurse Practitioner was informed of these elevated levels.
A resident with hemiplegia and hemiparesis filed a grievance requesting therapy services, which was not addressed in a timely manner by the facility. Despite the resident's request and a grievance filed on 8/5/2024, therapy services were not initiated until a physician's order was made on 9/21/2024. The facility's policy required prompt resolution of grievances, but the delay was attributed to issues with Medicaid funding and staffing for restorative programs.
The facility failed to complete Significant Change MDS assessments within the required 14 days for two residents receiving hospice services. One resident with multiple diagnoses, including COPD and traumatic brain injury, had a delayed assessment after hospice initiation. Another resident with conditions like epilepsy and diabetes also experienced a delay in assessment following hospice service commencement. The Regional MDS Nurse confirmed the assessments should have been completed within the specified timeframe.
The facility failed to maintain grooming for three residents, leading to deficiencies in their ADLs. A resident was observed with long nails and a dark substance underneath, despite requiring assistance. Another resident expressed that staff had not offered to shave him, and observations confirmed increased facial hair growth and long nails. A third resident was found with long fingernails and a dark substance underneath, with no documentation of refusals for care. Interviews with CNAs indicated they provided general ADL care but did not specifically address grooming needs.
A resident with a pressure ulcer on the back of his left upper thigh did not receive adequate treatment and monitoring. Despite reporting the sore weeks prior, the dressing was inconsistently changed, and staff were unaware of the wound care needs. The resident's medical history included chronic venous hypertension and peripheral vascular disease. Facility policies on wound care were not followed, resulting in inadequate management of the pressure ulcer.
A resident with Medicaid was not provided equal access to rehabilitation services at the facility. Despite having a physician's order for therapy, the resident experienced a delay in receiving an evaluation and therapy services due to the facility's policy requiring Administrator approval for Medicaid admissions. The resident, who had significant medical conditions affecting mobility, had requested therapy but did not receive it until later, highlighting a failure to adhere to the facility's policy on specialized rehabilitation services.
Failure to Notify Physician of Medication Errors and Resident Decline
Penalty
Summary
The facility failed to ensure timely notification of a physician when a resident, identified as Resident B, was given medication in the incorrect form, refused all medications for six consecutive medication passes, and experienced a decline in level of consciousness. Resident B had a complex medical history including stroke, seizures, heart failure, hypertension, diabetes, and dementia. The resident's Medication Administration Record (MAR) indicated that from March 1 to March 3, 2025, the resident did not receive any prescribed medications due to refusals and incorrect administration. On March 2, 2025, the resident's medications were not administered due to charted nausea and vomiting, although it was later clarified that the resident had refused the medications. On March 3, 2025, the resident continued to refuse medications and meals, and was noted to be very difficult to arouse. Despite these significant changes in condition, there was no documentation of physician notification until the resident's representative requested medical attention. The resident was eventually sent to the hospital for evaluation and treatment after the family insisted. Interviews with facility staff revealed that the resident's Depakote ER was crushed, which is against proper administration guidelines, and that the resident's lack of responsiveness and medication refusals were not promptly communicated to the physician. The facility's policy on notification of changes was not followed, as significant changes in the resident's condition were not reported in a timely manner, leading to a delay in appropriate medical intervention.
Lack of Comprehensive Care Plans for Resident with Multiple Diagnoses
Penalty
Summary
The facility failed to ensure comprehensive care plans were in place for a resident with multiple medical conditions, including type 2 diabetes, seizures, bipolar disorder, congestive heart failure, and anxiety. Upon review of Resident B's medical records, it was found that despite being admitted in September 2024 with these diagnoses, there were no care plans addressing these conditions or the medications prescribed for them. The resident was on several high-risk medications, including antipsychotics, antidepressants, and a diuretic, yet the necessary care plans to manage these conditions and medications were absent. During an interview, the MDS nurse confirmed that Resident B did not have care plans for the listed diagnoses and medications, which should have been established upon admission and when the medications were prescribed. The facility's policy mandates the development and implementation of comprehensive, person-centered care plans that include measurable objectives and timeframes to meet the resident's needs. However, this policy was not adhered to in the case of Resident B, leading to the deficiency cited in the report.
Failure to Manage Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to ensure that Physician Orders were in place for the treatment of low blood glucose and did not assess hypoglycemia in a timely manner for Resident B, who was one of three residents reviewed for diabetic treatment. Resident B had a history of stroke, seizures, heart failure, hypertension, diabetes, hyperlipidemia, dementia, and chronic obstructive pulmonary disease. Despite being severely cognitively impaired, Resident B was sometimes able to communicate his needs. The resident was on multiple medications for type 2 diabetes, but there were no orders for hypoglycemia management or a plan of care addressing the diabetes diagnosis. On a specific day, Resident B was reported to be very difficult to arouse and had not taken his medications due to lack of alertness. The resident's family requested hospital evaluation due to his unresponsiveness. The Emergency Department noted a critically low blood glucose level of 18 mm/dl, indicating hypoglycemia and altered mental status. Interviews with facility staff revealed that the resident's condition had been declining, and although vital signs were checked, blood sugar levels were not monitored. The facility's policy required glucose monitoring and treatment orders for residents at risk of hypoglycemia, which were not in place for Resident B.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of significantly elevated blood glucose levels for a resident diagnosed with Type 2 diabetes. The physician's order required notification if the resident's blood glucose levels were below 60 mg/dL or above 400 mg/dL. However, the facility did not document any notification to the physician when the resident's blood glucose levels exceeded 400 mg/dL on multiple occasions. Specifically, the resident's blood glucose levels were recorded as 420 mg/dL, 433 mg/dL, 450 mg/dL, and 416 mg/dL on different dates, yet there was no evidence that the physician was informed of these elevated levels. Interviews with facility staff, including the Administrator, Director of Nursing (DON), and RN 5, revealed that the elevated blood glucose levels should have been documented in a nursing progress note or the triage book. However, a review of the triage binders on both the resident's previous and current halls showed no notes indicating that the Nurse Practitioner (NP) was contacted regarding the resident's out-of-range blood glucose levels. The facility's policy on Notification of Changes, which was undated, stated that the facility should promptly inform the resident, consult the physician, and notify the resident's representative when there is a change requiring notification. Despite this policy, the required notifications were not made in this case.
Delayed Response to Resident's Grievance for Therapy Services
Penalty
Summary
The facility failed to respond to a resident's grievance in a timely manner, specifically regarding the request for therapy services. Resident L, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, expressed during an interview that he had not received the therapy he sought upon admission. He had filed a grievance on 8/5/2024, expressing concerns about the wait time for colostomy care and the need for therapy. The grievance form indicated a resolution on the same day, but the resident did not receive therapy services until a physician's order was made on 9/21/2024. The Director of Rehab noted that she could not evaluate new admissions with Medicaid funding without the Administrator's permission, and the Administrator confirmed that the facility did not offer a restorative program due to staffing and reimbursement issues. Despite the resident's request and the grievance filed, the Administrator did not provide a satisfactory explanation for the delay in addressing the grievance. The facility's policy required prompt efforts to resolve grievances, but the resolution for Resident L's request for therapy was delayed significantly.
Failure to Timely Complete Significant Change MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment in a timely manner for two residents who were receiving hospice services. Resident 16, with diagnoses including chronic obstructive pulmonary disease, traumatic brain injury, depression, bipolar disorder, and anxiety disorder, had a hospice contract initiated on March 28, 2024. However, the Significant Change MDS assessment was not completed until June 19, 2024, which was not within the required 14 days after the initiation of hospice services. The Regional MDS Nurse confirmed that the assessment should have been completed within 14 days of the hospice services initiation. Similarly, Resident 28, who had diagnoses including epilepsy, type 2 diabetes mellitus, Crohn's disease, dysphagia, spinal stenosis, and benign prostatic hyperplasia, had a hospice agreement dated August 2, 2024, with hospice services starting on August 12, 2024. The facility failed to complete a Significant Change MDS assessment within 14 days of the hospice order. The Regional MDS Nurse acknowledged that the assessment should have been completed within the specified timeframe. The facility does not have a specific policy for MDS assessments but follows the Resident Assessment Instrument (RAI) manual.
Deficiency in Grooming and ADL Care for Residents
Penalty
Summary
The facility failed to maintain proper grooming for three residents, leading to deficiencies in their activities of daily living (ADLs). Resident 15 was observed multiple times with long nails and a dark substance underneath them. Despite having a care plan indicating a self-care deficit and requiring assistance, there was no documentation of any refusals for nail care. Interviews with CNAs revealed that while they provided various aspects of ADL care, there was no mention of addressing nail care specifically. Resident L expressed that staff had not offered to shave him, despite his preference for a closer shave with a razor. His care plan required assistance with personal hygiene, including shaving, due to limited movement in his left arm. Observations confirmed increased facial hair growth and long nails with a brown substance underneath, with no documentation of refusals for care. Interviews with CNAs indicated they provided general ADL care but did not specifically address shaving or nail care. Resident 21 was also found with long fingernails and a dark substance underneath them. His care plan required staff assistance for grooming, but there was no documentation of refusals for hygiene or grooming assistance. Interviews with CNAs indicated they provided comprehensive personal care, including nail care, but there was no evidence of this being done for Resident 21. The facility's policy on ADLs included grooming, but the observations and interviews suggest a lack of adherence to this policy.
Inadequate Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide adequate treatment and monitoring for a pressure ulcer for Resident 37, who had a sore on the back of his left upper thigh. The resident reported the sore to the nursing staff 3-4 weeks prior, and it was attributed to his wheelchair cushion. Despite receiving a new cushion, the resident indicated that the dressing on the sore was only replaced every couple of days upon his request. Observations revealed that the dressing was undated, uninitialed, and showed visible drainage, indicating inadequate wound care management. The resident's medical history included chronic venous hypertension with ulcer of bilateral lower extremity and peripheral vascular disease. A significant MDS assessment indicated normal cognition. Progress notes from the wound care office detailed the wound's measurements and treatment plan, which included cleansing with soap and water, daily dressing changes with Medihoney Gel, and offloading with a cushion for pressure relief. However, interviews with nursing staff revealed a lack of awareness and documentation regarding the resident's wound care needs, with some staff indicating no wounds were being monitored or treated. The facility's policies on notification of changes, skin assessment, and clean dressing change were not adhered to, as evidenced by the lack of consistent documentation and communication regarding the resident's wound care. The DON indicated that wounds should be measured weekly, and new wounds should be documented, with treatment orders obtained. However, the resident's wound care was inconsistent, and staff failed to follow the established protocols, leading to inadequate treatment and monitoring of the pressure ulcer.
Failure to Provide Equal Access to Rehab Services for Medicaid Resident
Penalty
Summary
The facility failed to provide equal access to rehabilitation services for a resident with Medicaid as a payer source. Resident L, who had been admitted to the facility with the expectation of receiving therapy, reported that he had not received any range of motion exercises or therapy since his admission. Despite having a physician's order for physical therapy, the resident experienced a delay in receiving an evaluation and therapy services. The Director of Rehab indicated that she was unable to evaluate new admissions with Medicaid without the Administrator's permission, which contributed to the delay in Resident L's therapy evaluation and services. Resident L had significant medical conditions, including hemiplegia and hemiparesis following a cerebral infarction, which affected his left side. His admission Minimum Data Set assessment indicated he required assistance with personal hygiene, bathing, and transfers, and had impaired range of motion on his left side. A baseline care plan outlined the need for physical and occupational therapy to improve his functional status and minimize decline. However, the therapy services were not initiated until after the Administrator approved them, despite the resident's requests and the Director of Rehab's belief that he would benefit from therapy. The Administrator acknowledged that the facility did not offer a restorative program and that they did not receive reimbursement for therapy services for residents with Medicaid. This financial consideration appeared to influence the delay in providing therapy services to Resident L. The Administrator confirmed that Resident L had requested therapy and that his request was addressed in a written grievance. The facility's policy on specialized rehabilitation services indicated that such services are considered a facility service and should not be charged to Medicaid recipients, yet the delay in providing these services suggests a failure to adhere to this policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mishawaka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trailpoint Village | 2.5 mi | — | 18 | 0 |
| Brickyard Healthcare - Fountainview Care Center | 3.5 mi | — | 3 | 0 |
| Cardinal Nursing And Rehabilitation Center | 3.9 mi | — | 0 | 0 |
| Creekside Village | 4 mi | — | 14 | 0 |
| Belltower Health & Rehabilitation Center | 4.4 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.