Brickyard Healthcare - Twelfth Street Care Center
811 E 12th Street, Mishawaka, IN 46544 · For profit - Corporation · 87 certified beds · (574) 259-1917 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (68%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.8% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.3% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 24.3% | 25.2% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.9% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.5% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.7% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.9% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.9% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.1% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.0% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 70.6% | 79.0% | 79.4% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 35% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.5%CMS range 42.0–71.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.5–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 87 beds and averages 58.2 residents a day — about 67% occupied, or roughly 29 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.03 hrs/resident/day on weekends vs 3.48 on weekdays — 13% thinner on weekends. RN hours go from 0.75 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 68% is well above the national median of 45%. 4 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Fcited before2025-09-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Finding includes:During an observation of the breakfast meal service on 9/9/2025 at 8:03 A.M., the breakfast temperature log had not been filled out but meal trays had been given to residents. The CDM tempted a cup of milk and the temperature had been 44 degrees Fahrenheit. During the observation, 4 meal trays with cups of milk were taken from the kitchen window and delivered to residents. During an interview on 9/9/2025 at 8:04 A.M., the Certified Dietary Manager indicated the milk temperature was out of range and should not have been served. During an interview on 9/9/2025 at 8:05 A.M., the Chef 4 indicated everything that would be served at breakfast, including milk, had a temperature checked prior to meal service, but he had forgotten to fill out the temperature log. During an interview on 9/9/2025 at 8:07 A.M., RN 3 indicated she had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-12 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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)Findings include:1. During an observation on 9/12/2025 at 12:05 P.M., the surveyor knocked on Resident 48's door and the roommate opened the door all the way. Resident 48 was laying in bed naked except for a brief. The privacy curtain was open and the window curtain was partially open. CNA 12, who was providing care, turned to see who was at the door, turned back to Resident 48, and then turned to the door again. The surveyor had to instruct CNA 12 to pull the privacy curtain. During an interview on 9/12/2025 at 12:42 P.M., CNA 12 indicated she pulled the curtain to remind the roommate to use her walker when she gets up. She further indicated the privacy curtain and window curtain should have been closed. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-12 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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)Findings include:1.During an observation of the 200 hall medication cart on 9/10/2025 at 10:48 A.M. with Employee 15, the following was observed:There were 5 opened and undated bottles of polyethylene glycol.During an interview, on 9/10/2025 at 10:56 A.M., QMA 15 indicated the opened bottles of polyethylene glycol should have had open dates.2. Upon entrance to the facility, on 9/8/2025 at 5:55 P.M., the 100 hall medication cart was observed to be unlocked and a laptop was opened with resident information visible to passersby. During an interview, on 9/8/2025 at 5:58 P.M., RN 5 indicated she had left to attend to a resident's needs and she should have locked the medication cart and closed the laptop. On 9/9/2025 at 8:05 A.M., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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)Finding includes:During an interview on 9/10/2025 at 9:45 A.M., CNA 8 indicated they had been employed at the facility for fours years and regularly worked with Resident 11. CNA 8 indicated they had never seen Resident 11 confused, and Resident 11 was slow to respond, but had always been able to make his needs known. Resident 11 had seemed more depressed recently and CNA 8 indicated it was related to death of Resident 11's roommate and Resident 11's inability to leave the facility due to a WanderGuard.During a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-12 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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)Finding includes:The clinical record of Resident 39 was reviewed on 9/10/2025 at 3:13 P.M. The resident's diagnoses included, but were not limited to: chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, anxiety, depression, opioid dependence and mild cognitive impairment.A Quarterly Minimum Data Set (MDS) assessment, dated 7/3/2025, indicated Resident 39 was cognitively intact and had received an antidepressant, an anticoagulant, an opioid and a diuretic. A Physician's Order, dated 1/13/2025, indicated blood pressure checks were to be completed every shift to monitor for blood pressure drops. The September 2025 Medication Administration Record (MAR) indicated Resident 39 had a blood pressure measurement of 79 over 44 (normal adult = 120 over 80) on the night shift of September 1, 2025. Resident 39's clinical record failed to evidence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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)Finding includes:During an observation of medication administration on 9/10/2025 at 9:33 A.M. with QMA resident 9 was administered Midodrine Hydrochloride 5mg (milligrams) by mouth. Resident 9's blood pressure was142/58 mm/Hg (millimeters per mercury).A record review was completed for Resident 9 on 9/11/2025 at 11:24 A.M. Diagnoses included, but were not limited to: acute on chronic systolic heart failure, sick sinus syndrome, hypertension and stage 4 chronic kidney disease.A Physician's Order, dated 6/13/2025 indicated Resident 9 was to be administered Midodrine Hydrochloride 5mg by mouth three times per day. Additional instructions also indicated to hold Midodrine Hydrochloride 5mg if the resident's systolic blood pressure was greater than 140 mm/Hg.A review of Resident 9's EMAR (Electronic medication administration record) indicated the resident had been administered Midodrine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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)Finding includes:A record review for Resident 7 was completed on 9/10/2025 at 1:41 P.M. Diagnoses included, but were not limited to, urinary tract infection, type 2 diabetes mellitus, mild cognitive impairment, major depressive disorder, and chronic pain disorder. An admission Minimum Data Set (MDS) assessment, dated 7/31/2025, indicated Resident 7's cognition was intact, had functional limitations of the upper extremities on one side, used a wheelchair, required substantial to maximal assist for transfers and had one fall prior to reentry to the facility and no falls since reentry. A Care Plan problem, initiated on 7/28/2025, indicated Resident 7 had an Activities of Daily Living deficit with an intervention, revised on 9/5/2025, that required assist of 2 staff for transfers. Nursing Progress Notes, dated 8/26/2025, indicated Resident 7 was transferred with assist of one staff. His legs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to monitor nutritional status for 1 of 2 residents reviewed for nutrition. (Resident 4)Finding includes:A record review was completed on 9/11/2025 at 10:11 A.M. for Resident 4. Diagnoses included, but were not limited to, unspecified dementia and adult failure to thrive.An admission Minimum Data Set (MDS) assessment, dated 8/28/2025, indicated Resident 4's cognition was intact, needed set up/clean up assist for eating, and had no swallowing or chewing issues.A Physician Order, dated 8/20/2025, indicated Resident 4's diet was regular with regular texture and no salt packet.A Care Plan, initiated on 8/21/2025, indicated Resident 4 had a nutritional problem related to self-reported chewing issue with prior unspecified weight loss. Staff were to monitor and signs or symptoms of dysphagia (difficulty swallowing) and serve diet as ordered.admission and September weights could not be found in the record. During an interview on 9/8/2025 at 7:15 P.M. Resident 4 indicated she had lost weight but wasn't sure how much. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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) Finding includes: During an observation on 9/9/2025 at 1:06 P.M., Resident 2's personal refridgerator had pop splattered and spilled on all sides of the inside of the fridge, on the inside door and on the shelf of the fridge. A container with grapes was removed and pop spilled onto the floor because pop accumulated on the lid of the grapes. There had not been a received on date or use by date on the grapes. An opened jar of nacho cheese had not been labaled with an opened on date or used by date. During an interview on 9/9/2025 at 1:08 P.M., Resident 2 indicated nobody checked the temperature of his fridge or cleaned it out. He believed his sister had been the one cleaning the fridge in the past. During an interview on 9/9/2025 at 1:10 P.M., the Executive Director (ED) indicated Resident 2's personal fridge was dirty and should not have been and all opened food should have an opened on or used…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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). Finding includes: On 3/17/25 at 11:28 A.M., Resident B's medical record was reviewed. Diagnoses included, but were not limited to: history of stroke, seizures, heart failure, hypertension, diabetes, hyperlipidemia, dementia, chronic obstructive pulmonary disease, other symptoms involving emotional state. A Quarterly Minimum Data Set (MDS) assessment, dated 2/5/25, indicated Resident B was severely cognitively impaired, was sometimes able to make his his needs and ideas known and had rejected care 1 to 3 days in the 7 day look back period of the assessment. Physician orders for medications and supplements included- Glyburide 5 mg tablet 2 times daily for type 2 diabetes Ploglitazone HCL 15 mg tablet 1 time daily for type 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2025-03-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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) Finding includes: On 3/17/25 at 11:28 A.M., Resident B's medical record was reviewed. Upon admission in September 2024, Resident B had diagnoses which included type 2 diabetes, cerebral infarction (stroke) with other symptoms and signs involving emotional state, vascular dementia, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and seizures. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B had diagnoses that included stroke, heart failure, hypertension, diabetes, hyperlipidemia, dementia, chronic obstructive pulmonary disease, other symptoms involving emotional state. The assessment indicated the resident received the following High risk medications: antipsychotics, antidepressants, and a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Finding includes: On 3/17/25 at 11:28 A.M., Resident B's medical record was reviewed. Diagnoses included history of stroke, seizures, heart failure, hypertension, diabetes, hyperlipidemia, dementia, chronic obstructive pulmonary disease, other symptoms involving emotional state. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B was severely cognitively impaired and was sometimes able to make his his needs and ideas known. Physician's orders included the following medications: -Glyburide 5 mg tablet 2 times daily for type 2 diabetes, ordered 9/26/24. -Ploglitazone HCL 15 mg tablet 1 time daily for type 2 diabetes, ordered 9/26/24. -Sitaglipin Phosphate 100 mg tablet every evening for type 2 diabetes, ordered 9/26/24. -Steglatro…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-26 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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). Finding includes: On 9/23/2024 at 11:06 A.M., a record review was completed for Resident 45. Diagnosis included, but were not limited to: Type 2 diabetes A Physicians' order, dated 7/30/2024, indicated the provider was to be notified if Resident 45's blood glucose levels were below 60 mg/dl or above 400 mg/dL. A review of Resident 45's blood glucose results indicated the record lacked documentation the physician was notified of elevated blood glucose levels above 400 mg/dl for the following dates and times: - On 9/13/2024 at 12:33 P.M., Resident 45's blood glucose level was 420n mg/dl. - On 9/15/2024 at 1:08 P.M., the residents blood glucose level was 433 mg/dl. - On 9/20/2024 at 11:41 A.M., the residents blood glucose level was 450 mg/dl and at 5:06 P.M., the residents blood glucose level was 416 mg/dl. During an interview, on 9/23/2024 at 1:37 P.M., the Administrator indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0585 — failed to handle grievances — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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) Finding includes: During an interview on 9/19/2024 at 2:23 P.M., Resident L indicated no one had done range of motion exercises with him, nor had he received any therapy. He indicated he came to the facility so he could get therapy, and he did ask the Administrator for therapy. A record review was completed, on 9/23/2024 at 2:13 P.M., for Resident L. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, spastic hemiplegia affecting left nondominant side, and colostomy status. A Grievance Form, dated 8/5/2024, indicated Resident L was concerned with the wait time in the morning to get his colostomy bag dumped, and wanting further therapy. The form indicated it was resolved on 8/5/2024 with a response of discussed restorative options upcoming and the Medicaid payer. During an interview on 9/25/2024 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0621 — isolatedTreat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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) Finding includes: During an observation and interview on 9/19/2024 at 2:23 P.M., Resident L indicated no one had completed range of motion exercises with him, nor had he received any therapy. He indicated he came to the facility so he could receive therapy and he had asked for therapy. His left leg was no longer straight, he could not open up his hand and had lost range of motion to his left arm. He had received a soft splint to the left hand prior to his admission to the facility but had to ask for someone to put it on him. In addition, he also had an ankle foot orthosis (AFO) for his left foot but felt it was too tight. A record review was completed on 9/23/2024 at 2:13 P.M., for Resident L. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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) Findings include: 1. Resident 16's record review was completed on 9/23/2024 at 3:10 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, traumatic brain injury, depression, bipolar disorder and anxiety disorder. Resident 16 had a signed hospice contract, initiated on 3/28/2024. A current Physician's order indicated Resident 16 had been receiving Hospice services since 3/28/2024. A Quarterly MDS assessment, dated 3/19/2024, indicated Resident 16 was not receiving Hospice services. A Significant Change MDS assessment, dated 6/19/2024, indicated the resident was receiving Hospice services. Resident 16's record lacked the documentation a Significant Change MDS had been completed timely after the Physician's order was received on 3/28/2024 for Hospice services. During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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) Findings include: 1. During an observation and interview on 9/19/2024 at 1:53 P.M., and 9/20/2024 at 1:53 P.M., Resident 15's nails were long with a dark substance under them. He indicated no one had offered to clean or trim his nails. During an observation on 9/23/2024 at 9:14 A.M. and 9/24/2024 at 9:17 A.M., Resident 15's nails were long with a dark substance under them. A record review was completed, on 9/25/2024 at 11:36 A.M., for Resident 15. Diagnoses included, but were not limited to: Parkinson's Disease without dyskinesia, chronic kidney disease stage 3, and chronic embolism and thrombosis of deep veins of right upper extremity. An admission Minimum Data Set (MDS) assessment, dated 8/9/2024, indicated Resident 15 required substantial/maximal assistance for personal hygiene and bathing. A current Care Plan, initiated on 8/1/2024, for activities of daily living indicated Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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) Finding includes: During an interview and observation on 9/19/2024 at 11:04 A.M., Resident 37 indicated he had a sore on the back of his left upper thigh. He told the nurse about it 3-4 weeks ago. The dressing covering the sore came off and he told the nurse and she was going to replace it. He indicated the sore was caused by his wheelchair cushion and they gave me a new cushion. The residents skin was observed and there was a circular crater the size of a nickel with swollen, raised edges and loose skin around the edges. Resident 37 indicated staff placed a patch on the wound every couple of days when he asked for one. During an observation and interview on 9/20/2024 at 9:31 A.M., Resident 37 indicated the facility placed a patch on his wound yesterday around 1 P.M. There was a white dressing undated, no initials and there was visible drainage coming through the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-26 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Finding includes: During a tour of the laundry room on 9/26/2023, from 9:06 A.M. to 9:15 A.M. two of the dryers' lint traps were inspected and both had a thick layer of white lint covering the filter and pieces of lint on the floor of the machine. Both dryers were full of a completed load inside. A log titled, Dryer Clean Out Schedule, was taped to the first dryer without an initial from the laundry aide indicating that it was cleaned at 6:00 A.M. and 8:00 A.M. for 9/26/2023. During an interview, on 9/26/2023 at 9:06 A.M., The Maintenance Director indicated that the lint trap is emptied every 2 hours. During an interview, on 9/26/2023 at 9:11 A.M., the Laundry Aide indicated that she did not clean out the lint traps since she has been here this morning and it should have been cleaned out every two hours at 6 and 8 A.M. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: During an observation and tour of the kitchen with the Dietary Manager, on 9/19/2023 at 9:15 A.M., the following was observed: -The freezer contained bags of frozen fish that were open and not resealed or dated and cups of ice cream were not dated. -The walk-in refrigerator contained soup, diced ham, and magic cups that were not dated. It also contained a bag of chicken patties, dinner rolls, and lettuce that were open, not resealed and not dated. -The dry storage area had containers of gravy. Italian dressing, cans of evaporated milk, parsley flakes, and garden seanoning that were not dated, and packages of pasta, dried cranberries, and cereal that were opened and not resealed or dated. -There was visible black grime on the floor and baseboards in various areas. -The vinyl tile floor was chipped where it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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) Finding includes: A record review was completed for Resident 29 on 9/20/2023 at 1:00 P.M. Diagnoses included, but were not limited to: cerebrovascular disease, anxiety disorder and major depression. A Progress Note, dated 8/15/2023 at 8:01 A.M., indicated that Resident 29 was found lying on her back in front of unlocked wheelchair in her room. Her right shoulder was asymmetrical compare to the left shoulder. An x-ray of right shoulder was completed and an intervention to remove bed chuck from the wheelchair seat. A Post Fall Evaluation, dated 8/24/2023 at 5:37 P.M., indicated unwitnessed fall in the resident's room, she was getting up alone. An Interdisciplinary Team (IDT) Progress Note, dated 8/25/2023 at 1:00 P.M. indicated the intervention was for staff to increase observation and offer assist with mobility as able. A Progress Note, dated 9/8/2023 at 6:46 P.M., indicated an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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) Findings include: 1. A record review was completed for Resident 3 on 9/21/2023 at 10:45 A.M. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and chronic obstructive pulmonary disease. A Quarterly Minimum Data Set (MDS) assessment, dated 7/7/2023, indicated extensive assist of one staff for personnel hygiene and total dependent for bathing. During an observation, on 9/20/2023 at 10:24 A.M., Resident 3 was in bed his right hand fingernails had a brown substance under the nails. During an observation, on 9/21/2023 at 9:47 A.M., Resident 3 was in bed his right hand fingernails had a brown substance under the nails. During an observation, on 9/25/2023 at 1:19 P.M., resident was in bed his right hand fingernails had a brown substance under them. A Care Plan, dated 6/19/2023, indicated .I have an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-26 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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) Finding includes: 1. A record review was completed on 9/20/2023 at 2:31 P.M. Resident 19's diagnoses included, but were not limited to: toxic encephalopathy, bipolar disorder, opioid abuse, and history of traumatic brain injury. Current Physician Orders, dated 6/23/2023 to 9/20/2023, indicated Resident 19 was to have had an evaluation and treatment provided by psychiatric services. The clinical record lacked any documentation to show that the evaluation/treatment had been completed. A current care plan, dated 6/26/2023, indicated that Resident 19 had mental health needs that would be resident to express mental health needs, articulation of mental health needs and skilled staff members providing opportunities to identify mental health needs. During an interview, on 9/22/2023 at 2:55 P.M., the Area [NAME]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-26 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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) Findings include: 1. A record review was completed for Resident 18 on 9/20/2023 at 1:30 P.M. Diagnoses included, but not limited to: hemiplegia and hemiparesis cerebrovascular disease, dementia without behavioral disturbances, major depressive disorder, Parkinson's, and dysphagia. A Physician Order, dated 7/26/2023, indicated regular diet, mechanical soft, thickened liquid nectar, mildly thick consistency. A Care Plan, dated 6/27/2023, indicated, .I have a Diet alteration related to: Dysphagia. I require mechanical soft/easy chew diet nectar thickened liquids During an observation, on 9/20/2023 at 1:34 P.M., resident 18 was in bed and had a styrofoam cup with just a little bit of thin liquids left and an orange print plastic bottle with a clear liquid on the bedside table. The resident indicated she drank the water and the plastic bottle is drinking water. During an interview, on 9/20/2023 at 1:35 P.M.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-26 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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) Findings include: 1. During an interview, on 9/19/2023 at 2:56 P.M., Resident 32 indicated she had not attended a care conference to discuss her plan of care. A record review, conducted 9/21/2023 at 10:15 A.M., indicated Resident 32's diagnoses included, but were not limited to: COPD, heart failure, migraine, fibromyalgia, and type 2 diabetes mellitus. A Significant Change Minimum Data Set (MDS) assessment, dated 7/23/2023, indicated Resident 32's cognition was intact. Care Plan Meeting minutes, for 5/4/2023 and 5/18/2023, indicated Resident 32 attended the meeting. The record lacked any documentation of meetings before or since those dates. Resident 32 was admitted to Hospice on 7/17/2023, which required a Significant Change MDS (Minimum Data Set) assessment, but the record lacked documentation of a care plan meeting with the resident and hospice to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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) Finding includes: A record review was completed for Resident 18 on 9/20/2023 at 1:30 P.M. Diagnoses included, but not limited to: hemiplegia and hemiparesis cerebrovascular disease, dementia without behavioral disturbances, major depressive disorder, Parkinson's, and dysphagia. Resident 18 was admitted to the facility on [DATE]. A copy of CHIRP-Patient Vaccination was scanned in under miscellaneous, it indicated that she had one COVID vaccine on 11/23/2021, last influenza vaccine on 10/17/2017 and no history of pneumococcal in the community. During an interview, on 9/26/2023 at 11:29 A.M., the Infection Preventionist indicated she did not have any signed vaccination consents in her admission Agreement indicating she would like to have a COVID booster, pneumococcal or influenza vaccine. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-09-12 · tag F0912 — widespreadProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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]) Finding includes: During an environmental tour, conducted on 9/11/2025 between 11:00 A.M. - 11:45 A.M., the following multiple rooms were observed to contain less than 80 square feet per resident. The following rooms were certified SNF/NF (Skilled Nursing Facility/ Nursing Facility) for three beds and measured from 70.5 - 72 square feet per resident: room [ROOM NUMBER], 2 beds, 211.5 total square feet, 105.75 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room [ROOM NUMBER], 2 beds, 216 total square feet, 108 square feet per resident.room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-09-26 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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) Findings include: 1. A record review was completed on 9/21/2023 at 10:04 A.M. Diagnoses included, but not limited to: end stage heart failure, type 2 diabetes, and peripheral vascular disease. Resident 35 was admitted on [DATE]. During a resident interview, on 9/19/2023 at 11:01 A.M., Resident 35 indicated he has had no type of meeting about his plan of care with the Social Worker or nursing. During an interview, on 9/21/2023 at 11:55 A.M., the Area [NAME] President indicated that they prefer under the assessment tab to initiate the Baseline Care Plan. Documentation of a baseline care plan could not be located under the assessment tab, or in the progress notes. The MDS Nurse initiated on 7/21/2023 care plans under the care plan tab and she should have reviewed them with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to BRICKYARD HEALTHCARE — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 2.4 | -1.4 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 22 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GEE, WILLIAM | Individual | CONTRACTED MANAGING EMPLOYEE | since 03/07/2023 |
| ENGELS, ERIN | Individual | CORPORATE DIRECTOR | since 10/25/2014 |
| GENTRY, MARK | Individual | CORPORATE DIRECTOR | since 01/12/2022 |
| STARKEY, TYLER | Individual | CORPORATE DIRECTOR | since 08/01/2020 |
| WAITE, JOHN | Individual | CORPORATE DIRECTOR | since 08/01/2020 |
| WHICKER, TIMOTHY | Individual | CORPORATE DIRECTOR | since 01/12/2022 |
| FENOUGHTY, DEANNA | Individual | CORPORATE OFFICER | since 07/10/2023 |
| MISHAWAKA OPERATING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2012 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $357K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155109. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.