C-
59/100BRIARCLIFF HEALTH & REHABILITATION CENTER Inspection Report, Violations & Safety Grade (SOUTH BEND, Indiana)
5024 WESTERN AVENUE, SOUTH BEND, Indiana 46619
Phone: 5743184600
CMS Overall:2/5
Overview & Bed Count
Certified Beds
131
Avg Residents/Day
94.6
Ownership
Non profit - Other
Provider Type
Medicare and Medicaid
County
St. Joseph
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing3/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Indiana Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.31 | 0.68 | -0.37 |
| Total Nurse Hours per Resident per Day | 4.30 | 3.73 | +0.57 |
| CMS Staffing Rating | 3/5 | 2.6/5 | - |
| Nursing Staff Turnover | 49.6% | 45.9% | - |
Health Citation History
19 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-03-19 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-08-08 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | G – Actual Harm |
| 2025-08-08 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-08-08 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-08-12 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | G – Actual Harm |
| 2024-08-12 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-08-12 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-08-12 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-08-12 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-08-12 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2024-08-12 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
| 2024-08-12 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D – Moderate Harm Potential |
| 2023-11-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2023-07-14 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2023-07-14 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2023-07-14 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-07-14 | Quality of Life and Care Deficiencies | Assist a resident in gaining access to vision and hearing services. | D – Moderate Harm Potential |
| 2023-07-14 | Quality of Life and Care Deficiencies | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D – Moderate Harm Potential |
| 2023-07-14 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
Fire Safety Citation History
32 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-09-17 | Construction Deficiencies | Meet requirements for sections of health care facilities separated by fire resistive construction. | E – Moderate Harm Potential |
| 2025-08-08 | Egress Deficiencies | Install proper backup exit lighting. | F – Moderate Harm Potential |
| 2025-08-08 | Smoke Deficiencies | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F – Moderate Harm Potential |
| 2025-08-08 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2025-08-08 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-08-08 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | F – Moderate Harm Potential |
| 2025-08-08 | Egress Deficiencies | Have exits that are accessible at all times. | E – Moderate Harm Potential |
| 2025-08-08 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2025-08-08 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2025-08-08 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2025-08-08 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2025-08-08 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2025-08-08 | Smoke Deficiencies | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | E – Moderate Harm Potential |
| 2025-08-08 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2025-08-08 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | E – Moderate Harm Potential |
| 2024-08-12 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2024-08-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-08-12 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2024-08-12 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2024-08-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | E – Moderate Harm Potential |
| 2024-08-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2023-07-14 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2023-07-14 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | F – Moderate Harm Potential |
| 2023-07-14 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2023-07-14 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2023-07-14 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | F – Moderate Harm Potential |
| 2023-07-14 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2023-07-14 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2023-07-14 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E – Moderate Harm Potential |
| 2023-07-14 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2023-07-14 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | C – Minimal Harm Potential |
| 2023-07-14 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | C – Minimal Harm Potential |
Total Penalties & Fines
$10,839
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-08-12 | Fine | $10,839 | - |
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the SOUTH BEND area at no cost.
Find Safe, Vetted Facilities Near SOUTH BEND
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the SOUTH BEND area at no cost.
Find Safe, Vetted Facilities Near SOUTH BEND
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.