Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Briarcliff Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cervical spine hardware, spinal cord dysfunction, and non-ambulatory status, who required two-person assistance and an EZ stand mechanical lift for transfers, was being moved from bed to wheelchair when the sit-to-stand sling strap snapped, causing the resident to fall to the knees and graze the neck on the bed frame. The CNA reported checking the sling before use and seeing no issues, but later observation showed the strap had torn off at its attachment point, the rings were stiff, and the label was torn and faded with no visible manufacturer directions. Manufacturer guidance required pre-use condition checks, non-use of slings with illegible tags, and replacement of reusable slings every six months, and further guidance noted that faded/missing tags and stiff, brittle straps indicate deterioration and loss of tensile strength, meaning such slings should not be used for lifting.
A resident with cervical stenosis, spinal cord dysfunction, and significant upper and lower extremity weakness, who was non-ambulatory and dependent on staff for transfers, was being moved from bed to wheelchair using a sit-to-stand mechanical lift with two CNAs when the sling strap broke, causing the resident to fall to the knees and graze the head/neck on the bed frame. The care plan required use of an EZ stand lift with two staff and directed staff to inspect slings for visible wear or decreased integrity. After the fall, the sling was found to have a strap torn off at its attachment point, stiff rings, and a torn, faded, illegible label with the resident’s name written over it. Manufacturer and external guidelines specified that slings with fraying, visible wear, illegible wash tags, or stiff/brittle straps should not be used and that reusable slings should be replaced at defined intervals.
A resident with schizoaffective disorder, mild ID, anxiety, and dementia had a known history of inserting foreign objects into his rectum, and the care plan included interventions to limit access to objects and monitor behaviors. Staff later found the resident with blood on his sheets, a pumpkin and a butter knife involved in the rectal injury, and he reported inserting a straw as well. He was sent to the hospital and required an exploratory laparotomy, loop colostomy, rectal wound repair, a JP drain, an indwelling catheter, and blood transfusions. RN and CNA staff said they were unaware of the history and did not check his rectum, room, or meal utensils, and leadership had discontinued one utensil-tracking intervention after the behavior was not recently observed.
Improper labeling and storage of refrigerated food was observed in the kitchen and Memory Care kitchenette. Surveyors found multiple sandwiches, vegetables, cheese, leftovers, pureed watermelon, and store-bought food items without required dates or resident identification, and several items were past their use-by dates. The DD stated that all food should be labeled with made-on/opened-on and use-by dates, leftovers should be discarded after 3 days, and food brought in for residents should be labeled with the resident's food.
Failure to Report Resident Injury Incident: A resident with schizoaffective disorder, mild ID, anxiety, and dementia was found with blood on his sheets after inserting objects into his rectum, including a small pumpkin, a butter knife handle, and reportedly a straw. The resident required EMS transport and hospital care, including an ostomy, JP drain, and indwelling catheter, but the incident was not reported to the State Survey Agency despite the facility policy requiring reporting of unusual occurrences and reportable incidents.
A resident experienced severe pain during a wound dressing change because the facility failed to administer pain medication beforehand. Despite the resident's cries of pain, the ADON continued the procedure without ensuring pain relief, contrary to the care plan and physician's orders. The resident's pain management regimen included Morphine, Norco, and a Fentanyl patch, but a PRN dose of Morphine was not given prior to the dressing change.
The facility failed to ensure proper covering of residents' clothing during transport by laundry staff, leading to a deficiency in infection prevention and control. Observations showed that clothing was only partially covered, contrary to facility policy. Interviews revealed a lack of adequate cart covers, and staff acknowledged the need for better coverage.
A facility failed to include a resident with stage 5 chronic kidney disease, osteoarthritis, and type 2 diabetes in care plan meetings. Despite an intact cognition and participation in goal setting, the resident reported not attending any care plan meetings since admission. The Social Services Director admitted to not documenting a meeting with the resident, and the facility's policy mandates the inclusion of family or representatives in care planning.
A facility failed to implement fall prevention interventions for a resident with severe cognitive impairment and a history of falls. Despite being at high risk, the resident's room lacked the required 'Call don't Fall' signage and adaptive call light system. The facility did not adhere to its policy on accidents and supervision, resulting in a deficiency.
The facility failed to reconcile controlled substances on the 800 Hall medication cart, as required by policy. Missing signatures on the Shift Change Accountability Record indicated that controlled substances were not counted and reconciled by two staff members on multiple shifts. A QMA confirmed the expectation for dual staff verification, and the facility's policy mandates this practice.
The facility failed to ensure timely physician review and action on pharmacy recommendations for two residents, resulting in significant delays in medication changes. The DON acknowledged issues with the previous Medical Director's responsiveness, leading to the termination of his position.
The facility's kitchen had several sanitation deficiencies, including undated food items in the freezer, wet food processor bowls stored as clean, dusty ductwork and ceiling, a dusty electrical outlet, and pans with flaking Teflon coating. These issues were acknowledged by the Dietary Manager and had the potential to affect 88 residents.
The facility failed to maintain a sanitary environment in the 500 Hall, where a food cart was placed under a dusty air vent with condensation, causing mud-like droplets to fall onto the cart. All vents and surrounding ceiling tiles in the hall were covered in dust. The Director of Maintenance was initially unsure of the cleaning responsibilities, but later confirmed it was the maintenance department's duty. The facility's policy requires maintenance to ensure a sanitary environment.
Failure to Ensure Safe Condition of Mechanical Lift Sling Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a mechanical sit-to-stand lift sling was in good working order before use, resulting in a fall during transfer. A resident with surgically repaired cervical stenosis stabilized with rods and screws, spinal cord dysfunction, weakness of extremities, and non-ambulatory status required staff assistance and use of an EZ stand mechanical lift with two staff for transfers. The resident’s care plan and interventions identified the need for staff to inspect slings for visible signs of wear or decreased integrity and for therapy to confirm safety with sit-to-stand transfers and weight-bearing ability. On the day of the incident, two CNAs were transferring the resident from bed to wheelchair using the mechanical sit-to-stand lift. One CNA reported that she checked the sling and saw no issues before placing it around the resident’s back and under his arms, attaching the loops to the lift, and elevating him to a standing position. While the resident was standing, slightly bent forward, the sling strap snapped off where it attached to the body of the sling, causing the resident to fall to his knees, partially on the lift and partially on the floor, and graze the back of his head/neck on the bed frame. Initially, there were no visible injuries and no immediate complaints of pain, but later the resident reported dull, aching right knee pain and subsequently requested ER evaluation. Record review showed that the resident was diagnosed in the ER with a neck strain and a sprain to the right knee following the fall. Observation of the involved sling revealed that the strap had torn off at the attachment point to the sling body, the rings on the strap were intact but stiff, and the sling label was torn and faded with no visible manufacturer directions, with the resident’s name written over the torn label. Manufacturer guidelines provided by the DON stated that sling condition should be checked prior to use, that slings with illegible wash tags should not be used, and that reusable slings should be replaced every six months. Additional guidance from the manufacturer’s website indicated that completely faded or missing tags and strap brittleness or stiffness are indicators of deterioration and loss of tensile strength, even when the sling appears otherwise intact, and such slings should not be used for lifting a resident.
Failure to Ensure Mechanical Lift Sling Was in Safe Working Condition During Transfer
Penalty
Summary
The facility failed to ensure that staff used a sit-to-stand lift sling in good working order during a transfer, resulting in a fall for one resident. A confidential report alleged that the resident fell while being transferred from bed to wheelchair when the sling strap broke, causing the resident to fall to his knees and strike the back of his neck against the bed frame. Initially, the resident had no visible injuries or pain, but later developed increased pain in his knees and neck and was sent to the ER for evaluation, where he was diagnosed with a neck strain and a sprain to his right knee. The resident had diagnoses including surgically repaired cervical stenosis with rods and screws in the neck and spinal cord dysfunction with weakness of extremities. A recent MDS showed he had no cognitive impairment but had impaired range of motion and function in both upper and lower extremities, was non-ambulatory, used a wheelchair for mobility, and was dependent on staff for transfers. His care plan required use of an EZ stand mechanical lift with two staff for transfers and identified him as at risk for falls due to weakness and decreased mobility. Interventions included that staff were to inspect slings used for transfers for visible signs of wear or decreased integrity, and therapy was to confirm safety with sit-to-stand transfers and weight-bearing ability. On the day of the incident, two CNAs were transferring the resident with a mechanical sit-to-stand lift when the sling strap broke, causing the resident to fall to his knees, partially on the lift and partially on the floor, and graze his head/neck on the bed frame. One CNA reported that she had checked the sling before use and saw no issues, then placed the sling around the resident’s back and under his arms, attached the loops to the lift, and raised him to a standing position when the strap snapped. Subsequent observation of the sling showed the strap had torn off where it attached to the body of the sling, the rings on the strap were intact but stiff, and the label was torn and faded with no visible manufacturer directions, with the resident’s name written over the torn label. Manufacturer guidelines provided to the facility indicated that slings should not be used if there was fraying or visible wear and tear, if the wash tag was illegible, and that reusable slings should be replaced every six months, and additional guidance from an external source described that completely faded or illegible tags and strap brittleness or stiffness were indicators of deterioration and loss of tensile strength.
Failure to Manage Known Self-Injurious Behaviors
Penalty
Summary
The facility failed to implement effective, ongoing interventions to prevent behaviors for a resident with a known history of inserting foreign objects into his rectum. The resident had diagnoses including schizoaffective disorder, mild intellectual disability, anxiety disorder, and dementia, and his care plan identified a history of placing foreign objects in his rectum and behavioral problems related to his psychiatric and cognitive conditions. The care plan included interventions to discourage insertion of objects and to assist with limiting objects in the resident’s environment, and a physician’s order directed staff to monitor for multiple behaviors, including physical injury to self or others. On 11/23/2024, staff found the resident in his room with blood on his sheets. He was discovered to have a small pumpkin in his brief with the stem pointed toward the rectum, blood on the pumpkin stem, and a butter knife with only the handle visible outside the rectum. The resident also stated he had inserted a straw into his rectum. Emergency services were called, and the resident was transported to the hospital. He later required an exploratory laparotomy, loop colostomy placement, repair of two rectal wounds, a JP drain, an indwelling catheter, and two units of packed red blood cells. The record showed that the resident’s September, October, and November 2024 TARs documented only one behavior, on 9/19/2024, despite the known history of inserting objects into his rectum. During interviews, the RN assigned to the resident and the CNA assigned to him on the day of the incident stated they were not aware of his history and did not check his rectum, room for dangerous objects, or ensure utensils were accounted for after meals. The facility’s leadership stated the care plan intervention to track utensils at meals had been discontinued in April 2024 because the behavior had not been observed, and the PMHNP stated the resident did not understand the consequences of inserting a butter knife into his rectum.
Improper Labeling and Storage of Refrigerated Food
Penalty
Summary
Food was not stored in a sanitary manner because multiple items in the main kitchen refrigerator were not labeled or dated, and several foods were kept past their use-by dates. During the kitchen tour, surveyors observed two premade ham and cheese sandwiches without a made-on or use-by date, a plate of sliced tomatoes, onion, and shredded lettuce wrapped in plastic without dates, an opened bag of shredded cheese without an opened or use-by date, and a container of leftover green beans without a made-on or use-by date. Also found were a bag of celery labeled with a use-by date of 7/26/2025, a container of diced tomatoes labeled with a use-by date of 7/25/2025, and a container of cheese labeled with a use-by date of 7/20/2025. In the Memory Care Unit kitchenette refrigerator, surveyors observed two cups of pureed watermelon without a made-on or use-by date, a microwave meal in a grocery sack without resident information, and a container of cut-up watermelon from a local grocery store without a resident name or an opened-on or use-by date. The Dietary Director stated that all food should be labeled with a made-on and use-by date, food past the use-by or expiration date should be thrown away, leftovers removed from original containers were to be disposed of after three days, and food brought into the facility for residents should be labeled with the resident's food.
Failure to Report Resident Injury Incident
Penalty
Summary
The facility failed to report an unusual occurrence involving a resident who was found in his room with blood on his sheets and had inserted objects into his rectum. The resident, who had diagnoses including bipolar type schizoaffective disorder, mild intellectual disability, anxiety disorder, and dementia, was found with a small pumpkin in his brief with the stem pointed toward the rectum and blood on the pumpkin stem. Staff also observed a butter knife with only the handle of the blade outside the rectum, and the resident stated that he had inserted a straw into his rectum as well. Emergency Services, the physician, the ED, and the DON were notified, and paramedics transported the resident to the hospital. Record review showed the resident was admitted to a local hospital and received an ostomy, a JP drain, and an indwelling catheter as a result of injuries from the items inserted into the rectal cavity. Review of the facility-reported incidents showed that this event, which involved resident injury and hospitalization, was not reported to the Indiana State Survey Agency. During interview, the ED stated the IDT discussed the incident and believed it was an extension of the resident's current behavior and therefore did not need to be reported. The facility's Incident and Reporting Policy stated that all incidents, including abuse or unusual occurrences, must be reported and investigated promptly and that reportable incidents would be submitted to the State Survey Agency.
Failure to Administer Pain Medication Before Wound Care
Penalty
Summary
The facility failed to administer pain medication to a resident prior to a wound dressing change, resulting in severe pain during the procedure. During an observation, the resident expressed significant discomfort, repeatedly yelling in pain as the Assistant Director of Nursing (ADON) performed the wound care. The ADON acknowledged that the resident had not been given pain medication before the dressing change and was unsure if anyone else had administered it. The Unit Manager confirmed that the resident had been given Norco earlier in the day and could have received Morphine prior to the dressing change, but this was not done. The resident, who had a diagnosis of pressure ulcer, mild cognitive impairment, and dementia, was on a pain management regimen that included Morphine, Norco, and a Fentanyl patch. The Medication Administration Record indicated that the resident could have received a PRN dose of Morphine before the dressing change. The facility's policy on pain management emphasized recognizing and managing pain in accordance with the resident's care plan, which included administering pain medication as needed. Despite this, the dressing change proceeded without addressing the resident's pain, contrary to the care plan and physician's orders.
Inadequate Covering of Residents' Clothing During Transport
Penalty
Summary
The facility failed to ensure proper transportation of residents' clothing by laundry staff, leading to a deficiency in infection prevention and control. During observations, two laundry aides were seen transporting residents' personal clothing on carts that were only partially covered with a draw sheet, leaving the lower portion of the clothing exposed and uncovered. This was contrary to the facility's policy, which requires clean linens to be transported in a manner that ensures cleanliness and protection from dust and soil, such as using a properly cleaned cart with a secure cover. Interviews with the laundry aides and the Housekeeping/Laundry Director revealed that the facility did not have adequate covers for the carts, and the aides acknowledged that the clothing should have been covered more completely.
Failure to Include Resident in Care Plan Meetings
Penalty
Summary
The facility failed to include Resident 17, or her representative, in meetings to review her care plan. Resident 17, who has diagnoses including stage 5 chronic kidney disease, unspecified osteoarthritis, and type 2 diabetes mellitus, was admitted on 5/29/2024. An Admission Minimum Data Set (MDS) assessment dated 6/5/2024 indicated that her cognition was intact and she participated in goal setting. However, during an interview on 8/6/2024, the resident stated she had not attended a care plan meeting since her admission. A Social Service Progress Note from 5/30/2024 mentioned her goal of returning to the community after therapy, but there were no records of a care plan meeting being planned or conducted. The Social Services Director acknowledged meeting with the resident but failed to document the discussion. The facility's policy requires the comprehensive care plan to be prepared by an interdisciplinary team, including family members or others desired by the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident with a history of repetitive falls. Resident 10, who has severe cognitive impairment and requires extensive assistance for transfers, reported a fall that occurred the previous day, resulting in soreness. The resident's clinical record indicated multiple falls over the past year, with the most recent fall being unwitnessed and resulting in an equivocal fracture. Despite being at high risk for falls, as indicated by a recent Fall Risk Evaluation, the facility did not adhere to the interventions outlined in the resident's Care Plan. During an observation, it was noted that the resident's room lacked the 'Call don't Fall' signage and the adaptive touch pad call light system specified in the Care Plan. Interviews with the Unit Manager and Regional Nurse confirmed the absence of these interventions and highlighted a failure to update or remove outdated interventions from the Care Plan. The facility's policy on accidents and supervision, which emphasizes the implementation and communication of specific interventions to reduce risks, was not followed in this case.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to maintain a system for the reconciliation of controlled substances on one of the medication carts reviewed, specifically the 800 Hall medication cart. During an observation, it was noted that the Shift Change Accountability Record for Controlled Substances was missing signatures on several dates and shifts. These missing signatures indicated that the controlled substances had not been counted and reconciled by two staff members, as required by the facility's policy. The specific dates and shifts with missing signatures included the first shift on 8/1/2024, the first and third shifts on 8/4/2024, the third shift on 8/5/2024, the third shift on 8/6/2024, and the first shift on 8/7/2024. During an interview, a Qualified Medication Aide (QMA) confirmed that there should not be any missing signatures and that staff members are expected to count the controlled substances with another staff member, with both signing off on the count. The facility's policy, provided by the Unit Manager, stated that all scheduled II controlled substances should be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses, with both nurses signing the Shift/Shift Controlled Substance Count Sheet to acknowledge the count. This deficiency highlights a failure in adhering to the facility's policy for controlled substance reconciliation.
Delayed Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely review and action on pharmacy recommendations by a physician for two residents. For Resident 55, the pharmacist recommended discontinuing Cyanocobalamin and Biofreeze Gel, and initiating weekly blood glucose monitoring. However, there were significant delays in the physician's response and implementation of these recommendations, with the discontinuation of Cyanocobalamin and Biofreeze Gel taking several months, and the blood glucose monitoring order being delayed by over a month. The facility was unable to provide documentation of the physician's response dates for these recommendations. Similarly, for Resident 10, the pharmacist recommended discontinuing Pantoprazole and Atorvastatin. The physician agreed to these recommendations, but there were delays in discontinuing the medications, with Pantoprazole being discontinued nearly two months after the recommendation and Atorvastatin about two months later. The facility's Director of Nursing acknowledged issues with the previous Medical Director's responsiveness and had attempted to contact him multiple times without documented success. The facility eventually terminated the Medical Director's position due to these timeliness issues.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner in its kitchen, potentially affecting 88 out of 89 residents who consumed food prepared there. During an observation, it was noted that vegetable burgers, strawberries, and three tubs of ice cream in the reach-in freezer were not dated. Additionally, food processor bowls were stacked together while still wet, and the ductwork and ceiling in the food preparation area had a thick layer of dust. The electrical outlet above the spices was also dusty. Furthermore, two large and one small pans had missing and/or flaking Teflon coating on their cooking surfaces. The Dietary Manager acknowledged these issues, indicating that the food should have been dated, the bowls should have been dry before stacking, the ceiling, ductwork, and outlet should have been clean, and the Teflon pans should have been replaced.
Sanitation Deficiency in 500 Hall
Penalty
Summary
The facility failed to maintain a sanitary environment in the 500 Hall, as observed during a survey. A food cart was positioned under an air vent that had accumulated a thick layer of dust mixed with condensation, forming mud-like droplets that dripped onto the cart. Further inspection revealed that all five vents in the 500 Hall, along with the surrounding ceiling tiles and light covers, were covered in dust. One vent was particularly problematic, with condensation mixing with the dust and causing mud-colored droplets to fall to the floor. Interviews with the Director of Maintenance (DM) revealed uncertainty about whether the maintenance or housekeeping department was responsible for cleaning the vents and ceiling tiles. Initially, the DM attributed the condensation issue to residents opening their windows, which increased humidity levels. However, it was later clarified that the maintenance department was responsible for cleaning these areas. The facility's policy, titled 'Safe and Homelike Environment,' indicated that housekeeping and maintenance services should maintain a sanitary, orderly, and comfortable environment.
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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 South Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Bend Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 6 | 0 |
| Milton Home, The | 5.5 mi | ★★★★★ | 6 | 0 |
| Wellbrooke Of South Bend | 6 mi | ★★★★★ | 19 | 0 |
| Healthwin Health & Rehabilitation | 6.1 mi | ★★★★★ | 34 | 0 |
| Holy Cross Village At Notre Dame Inc | 6.1 mi | ★★★★★ | 20 | 0 |
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