Cycle 1
Health 2026-01-13 · Fire 2026-01-13
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
South Bend, IN
Southfield Village
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
6450 Miami Cir, South Bend, IN
(574) 231-1000
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
51
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Greencroft Communities
Operator or chain grouping
Approved since
2000-12-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 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
1.13
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.17
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.20
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,558
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9893
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.79
Baseline 20.11% · Performance 21.07% · Measure score 0.79 · Achievement 0.79 · Improvement 0
Healthcare-associated infections
6.87
Baseline 7.14% · Performance 5.78% · Measure score 6.87 · Achievement 6.87 · Improvement 5.84
Total nurse turnover
4.35
Baseline 51.47% · Performance 45.90% · Measure score 4.35 · Achievement 4.35 · Improvement 1.59
Adjusted total nurse staffing
2.31
Baseline 3.95 hours · Performance 3.73 hours · Measure score 2.31 · Achievement 2.31 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.85% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 9.17% · Lower 95% interval 7.51% |
| Discharge to community | 50.96% |
50.57%
0.4 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 49.11% · Lower 95% interval 42.8% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.71% |
95.27%
0.4 pts better
|
Numerator 67 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 68% |
53.69%
14.3 pts better
|
Numerator 34 · Denominator 50 |
| Discharge mobility score | 68% |
50.94%
17.1 pts better
|
Numerator 34 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 4.29% |
2.29%
2 pts worse
|
Numerator 3 · Denominator 70 · Adjusted rate 6.57% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 0% · Lower 95% interval 2.93% |
| Staff COVID-19 vaccination coverage | 1.96% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 102 |
| Staff flu vaccination coverage | 10.62% |
42%
31.4 pts worse
|
Numerator 12 · Denominator 113 |
| Discharge function score | 62% |
56.45%
5.5 pts better
|
Numerator 31 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 37.5% |
25.2%
12.3 pts better
|
Numerator 15 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
93.6%
7.7 pts worse
|
93.4%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 97.6% · Q3 48.7% · Q4 100.0% · 4Q avg 85.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
95.4%
2.3 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.8%
2 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.4% · Q3 0.0% · Q4 2.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
24.6%
24 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.6%
1.7 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
23.5%
14.3 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.6% · Q3 12.9% · Q4 10.0% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.8% |
14.8%
14 pts better
|
16.7%
15.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · 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 | 25.3% |
13.3%
12 pts worse
|
16.3%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.6% |
11.7%
20.9 pts worse
|
14.9%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 25.7% · Q3 32.3% · Q4 51.7% · 4Q avg 32.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.6% |
24.2%
8.4 pts worse
|
19.8%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 33.6% · Q3 26.5% · Q4 43.4% · 4Q avg 32.6% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.1%
2.4 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
81.6%
11.7 pts better
|
81.7%
11.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 97.5% · Q3 89.7% · Q4 85.9% · 4Q avg 93.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
10.5%
0.2 pts worse
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 10.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.1% |
79.0%
4.1 pts better
|
79.7%
3.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
22.4%
0.8 pts worse
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 23.2% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-31 · Fire 2024-10-31
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-10-31 · Fire 2023-10-31
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Not marked corrected
E · Potential for more than minimal harm
2026-01-13
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Not marked corrected
E · Potential for more than minimal harm
2026-01-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Not marked corrected
F · Potential for more than minimal harm
2024-10-31
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-10-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-10-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-10-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-31
F · Potential for more than minimal harm
2023-10-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-10-31
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-10-31
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-10-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-10-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-10-31
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-10-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-10-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-10-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-13
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.
Not marked corrected
E · Potential for more than minimal harm
2026-01-13
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.
Not marked corrected
E · Potential for more than minimal harm
2026-01-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Not marked corrected
E · Potential for more than minimal harm
2026-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Not marked corrected
F · Potential for more than minimal harm
2024-10-31
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 2024-11-30
D · Potential for more than minimal harm
2024-10-31
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 2024-11-30
D · Potential for more than minimal harm
2024-10-31
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 2024-11-30
D · Potential for more than minimal harm
2024-10-31
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 2024-11-30
D · Potential for more than minimal harm
2024-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-30
D · Potential for more than minimal harm
2023-10-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-30
Penalties and ownership
What sits behind the stars
Ownership
Woodlawn Hospital
5% Or Greater Direct Ownership Interest · Organization
Albright, Travis
Corporate Director · Individual
Day, Nancy
Corporate Director · Individual
Doran, Joseph
5% Or Greater Direct Ownership Interest · Individual
Fisher, Alan
Corporate Officer · Individual
Furnivall, Steven
Corporate Director · Individual
Heyde, Alison
Operational/Managerial Control · Individual
Heyde, Alison
Corporate Director · Individual
Johnson, Terri
Corporate Director · Individual
Mellinger, Gregory
Corporate Director · Individual
Southfield Village Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Trailpoint Village
South Bend, IN
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Brickyard Healthcare - Twelfth Street Care Center
Mishawaka, IN
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#3
Cardinal Nursing And Rehabilitation Center
South Bend, IN
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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