South Bend, IN

Cardinal Nursing And Rehabilitation Center

5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle

1121 E Lasalle Ave, South Bend, IN

(574) 287-6501

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

144

Certified beds

Average residents

56

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

American Senior Communities

Operator or chain grouping

Approved since

1970-05-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

91 facilities

Chain averages 4 overall / 3 health / 2 staffing / 5 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.70

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.64

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.35

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.68

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.33

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.90

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.66

CMS adjusted RN staffing hours

Adjusted total hours

3.49

CMS adjusted total nurse staffing hours

Case-mix index

1.44

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

33%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,680

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

25.99

Composite VBP score used to determine payment impact.

Payment multiplier

0.9840

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

4.32

Baseline 55.22% · Performance 46.03% · Measure score 4.32 · Achievement 4.32 · Improvement 2.53

Adjusted total nurse staffing

0.88

Baseline 2.74 hours · Performance 3.16 hours · Measure score 0.88 · Achievement 0 · Improvement 0.88

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 13 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 102
Staff flu vaccination coverage	23.16%	42% 18.8 pts worse	Numerator 22 · Denominator 95
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.4%	93.6% 0.8 pts better	93.4% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 94.8% · Q3 91.2% · Q4 100.0% · 4Q avg 94.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.4%	95.4% 3 pts better	95.5% 2.9 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4%
Percentage of long-stay residents experiencing one or more falls with major injury	2.2%	3.8% 1.6 pts better	3.3% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.4% · Q3 3.5% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.2%	24.6% 20.4 pts better	11.4% 7.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 2.0% · Q3 3.7% · Q4 1.9% · 4Q avg 4.2%
Percentage of long-stay residents who lose too much weight	6.6%	5.6% 1 pts worse	5.4% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 4.1% · Q3 8.2% · Q4 6.7% · 4Q avg 6.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.7%	23.5% 8.2 pts worse	19.6% 12.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 32.0% · Q3 34.0% · Q4 31.9% · 4Q avg 31.7%
Percentage of long-stay residents who received an antipsychotic medication	6.1%	14.8% 8.7 pts better	16.7% 10.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.1% · Q3 9.1% · Q4 3.1% · 4Q avg 6.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	4.7%	13.3% 8.6 pts better	16.3% 11.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 0.0% · Q3 4.0% · Q4 3.8% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.2%	11.7% 8.5 pts better	14.9% 11.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 4.2% · Q4 4.5% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.4% 0.4 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	1.2% 0.8 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.4%	24.2% 4.2 pts worse	19.8% 8.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 29.8% · Q3 34.2% · Q4 28.1% · 4Q avg 28.4%
Percentage of long-stay residents with pressure ulcers	3.0%	4.1% 1.1 pts better	5.1% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.3% · Q3 3.0% · Q4 4.7% · 4Q avg 3.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	65.7%	81.6% 15.9 pts worse	81.7% 16 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 61.9% · Q2 70.4% · Q3 75.0% · Q4 55.6% · 4Q avg 65.7%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	78.6%	79.0% 0.4 pts worse	79.7% 1.1 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 78.6%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-16 · Fire 2025-04-16

0 health deficiencies

No concentrated health issue counts in this cycle.

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2024-06-13 · Fire 2024-06-13

2 health deficiencies

Top issue: Environmental (1 deficiency)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2023-06-19 · Fire 2023-06-19

12 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-04-16

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-05-28

F · Potential for more than minimal harm 2024-06-13

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-07-25

E · Potential for more than minimal harm 2024-06-13

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-07-25

E · Potential for more than minimal harm 2024-06-13

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-07-25

F · Potential for more than minimal harm 2023-06-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-06-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-06-19

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-06-19

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-08-17

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-06-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-07-05

D · Potential for more than minimal harm 2024-06-13

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-07-05

D · Potential for more than minimal harm 2023-12-13

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2024-01-01

D · Potential for more than minimal harm 2023-11-09

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-12-02

E · Potential for more than minimal harm 2023-06-19

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-07-14