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
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 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
0.82
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.43
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
2.23
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,943
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.83
Composite VBP score used to determine payment impact.
Payment multiplier
1.0074
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.24
Baseline 17.35% · Performance 18.54% · Measure score 6.24 · Achievement 6.24 · Improvement 0
Healthcare-associated infections
6.67
Baseline 6.10% · Performance 5.84% · Measure score 6.67 · Achievement 6.67 · Improvement 1.82
Total nurse turnover
5.34
Baseline 36.49% · Performance 41.86% · Measure score 5.34 · Achievement 5.34 · Improvement 0
Adjusted total nurse staffing
2.88
Baseline 3.58 hours · Performance 3.90 hours · Measure score 2.88 · Achievement 2.88 · Improvement 0.93
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.38% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 285 · Observed rate 8.42% · Lower 95% interval 7.4% |
| Discharge to community | 68.71% |
50.57%
18.1 pts better
|
Better than the National Rate · Eligible stays 288 · Observed rate 63.54% · Lower 95% interval 63.35% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 161 · Denominator 161 |
| Falls with major injury | 1.24% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 161 |
| Discharge self-care score | 43.22% |
53.69%
10.5 pts worse
|
Numerator 51 · Denominator 118 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 59 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 8.07% |
2.29%
5.8 pts worse
|
Numerator 13 · Denominator 161 · Adjusted rate 9.75% |
| Healthcare-associated infections requiring hospitalization | 5.84% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 151 · Observed rate 3.97% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 140 |
| Staff flu vaccination coverage | 31.72% |
42%
10.3 pts worse
|
Numerator 46 · Denominator 145 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 59 · Denominator 118 |
| Transfer of health information to provider | 97.69% |
95.95%
1.7 pts better
|
Numerator 127 · Denominator 130 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.83% |
25.2%
9.6 pts better
|
Numerator 31 · Denominator 89 |
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 · Q1 100.0% · Q2 100.0% · Q3 90.7% · Q4 76.9% · 4Q avg 92.1% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 10.0% · Q2 4.7% · Q3 4.7% · Q4 2.6% · 4Q avg 5.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 2.8% · Q2 2.6% · Q3 11.9% · Q4 8.8% · 4Q avg 6.6% |
| 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 · Q1 13.9% · Q2 17.9% · Q3 21.4% · Q4 28.6% · 4Q avg 20.4% |
| 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 · Q1 8.8% · Q2 9.4% · Q3 10.8% · Q4 12.5% · 4Q avg 10.4% · 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 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 · Q1 22.6% · Q2 25.7% · Q3 27.5% · Q4 31.2% · 4Q avg 26.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 3.5% · Q4 3.8% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 2.5% · Q2 4.7% · Q3 4.7% · Q4 5.1% · 4Q avg 4.2% · Used in QM five-star |
| 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 · Q1 21.0% · Q2 13.8% · Q3 28.7% · Q4 27.1% · 4Q avg 22.4% |
| 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 · Q1 7.3% · Q2 6.6% · Q3 6.9% · Q4 6.9% · 4Q avg 7.0% · Used in QM five-star |
| 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 · Q1 99.6% · Q2 97.2% · Q3 93.9% · Q4 93.6% · 4Q avg 96.1% |
| 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 · Adjusted 11.5% · Observed 10.8% · Expected 10.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.3% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| 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 · 4Q avg 93.0% |
| 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 · Adjusted 24.6% · Observed 22.2% · Expected 21.4% · Used in QM five-star |
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
#1
Brickyard Healthcare - Fountainview Care Center
Mishawaka, IN
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
Jump out