Cycle 1
Health 2025-04-28 · Fire 2025-04-28
9 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
South Bend, IN
Holy Cross Rehabilitation And Wellness
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
17475 Dugdale Dr, South Bend, IN
(574) 247-7500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1994-01-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing
LPN hours / resident day
1.41
Licensed practical nurse staffing
Aide hours / resident day
2.20
Nurse aide staffing
Weekend hours
3.95
Weekend nurse staffing
RN turnover
69%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.1% |
93.6%
1.5 pts worse
|
93.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.8%
1.7 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
24.6%
24.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
23.5%
3.1 pts better
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
14.8%
4.4 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.8% |
11.7%
15.1 pts worse
|
14.9%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.4%
1.4 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
1.2%
3 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
24.2%
1.8 pts better
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
4.1%
2.9 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
81.6%
14.5 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
10.5%
1 pts worse
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.0% |
79.0%
14 pts better
|
79.7%
13.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
22.4%
2.2 pts worse
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-21 · Fire 2024-05-21
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-23 · Fire 2023-05-23
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-28
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-04-28
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-08-16
F · Potential for more than minimal harm
2025-04-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-04-28
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-04-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-04-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-04-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-04-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-06
F · Potential for more than minimal harm
2025-04-28
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-07-22
E · Potential for more than minimal harm
2025-04-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-22
E · Potential for more than minimal harm
2025-04-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-22
E · Potential for more than minimal harm
2025-04-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-22
E · Potential for more than minimal harm
2025-04-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-22
F · Potential for more than minimal harm
2024-05-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-22
E · Potential for more than minimal harm
2024-05-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-22
C · Minimal harm
2024-05-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-22
F · Potential for more than minimal harm
2023-05-23
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-05-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-23
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-17
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-04-28
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-28
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-28
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 2025-06-06
D · Potential for more than minimal harm
2025-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-28
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 2025-06-06
D · Potential for more than minimal harm
2024-06-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-22
E · Potential for more than minimal harm
2024-05-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-21
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
2024-05-21
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-05
D · Potential for more than minimal harm
2023-05-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-06-23
Penalties and ownership
What sits behind the stars
Ownership
Adams County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Anderson, Ray
Operational/Managerial Control · Individual
Battjes, Abigail
Operational/Managerial Control · Individual
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Bowens, Marcus
Operational/Managerial Control · Individual
Carter, Benjamin
Operational/Managerial Control · Individual
Drake, Daniel
Operational/Managerial Control · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Isacksen, Daniel
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Moore, Joshua
Operational/Managerial Control · Individual
Roth, Daniel
Operational/Managerial Control · Individual
Seppala, Christine
Operational/Managerial Control · Individual
Smith, Scott
Operational/Managerial Control · Individual
Smith, Scott
Corporate Officer · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Sprunger, Kyle
Corporate Officer · Individual
Trinity Continuing Care Services Indiana Inc
Operational/Managerial Control · Organization
Wheeler, Dane
Operational/Managerial Control · Individual
Wheeler, Dane
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Brickyard Healthcare - Fountainview Care Center
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2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Majestic Care Of South Bend
South Bend, IN
2-star overall rating with 1-star inspections with $116,322 in total fines with 8 recent health deficiencies with 24 fire-safety deficiencies in the latest cycle
#3
Creekside Village
Mishawaka, IN
4-star overall rating with 3-star inspections with 7 recent health deficiencies
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