01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-08 | 4 | 2025-08-08 | 15 |
| Cycle 2 | 2024-08-12 | 8 | 2024-08-12 | 6 |
| Cycle 3 | 2023-07-14 | 8 | 2023-07-14 | 11 |
CMS CCN 1558312026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Briarcliff Health & Rehabilitation Center
5024 Western Avenue · South Bend, IN 46619 · St. Joseph County
Certified beds131CMS provider file
Recent citation rows52current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
52 rows in the current release
3 rows carry G–L scope/severity codes; 0 carry J–L. 10 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-19 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-03-24 · complaint2025-09-17 · FIREK0131Severity E · pattern; potential for more than minimal harm
Construction Deficiencies
Meet requirements for sections of health care facilities separated by fire resistive construction.
Correction field: Deficient, Provider has date of correction · 2025-11-30 · complaint2025-08-08 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-09-122025-08-08 · HEALTHF0740Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Correction field: Deficient, Provider has date of correction · 2025-09-122025-08-08 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-09-122025-08-08 · FIREK0271Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2025-09-192025-08-08 · FIREK0281Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install proper backup exit lighting.
Correction field: Deficient, Provider has date of correction · 2025-10-042025-08-08 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2025-09-122025-08-08 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-09-262025-08-08 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2025-10-042025-08-08 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-09-122025-08-08 · FIREK0354Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2025-09-122025-08-08 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-09-122025-08-08 · FIREK0361Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Correction field: Deficient, Provider has date of correction · 2025-10-042025-08-08 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-09-122025-08-08 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-10-042025-08-08 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-10-042025-08-08 · FIREK0921Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2025-10-042025-08-08 · FIREK0927Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Correction field: Deficient, Provider has date of correction · 2025-09-262024-08-12 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-12 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-08-12 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-08-12 · HEALTHF0697Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-08-12 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-09-0403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-08-12 | Fine | $10,839 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MOKFI, SHAYAIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 01/01/2024
- CHRISMAN, KIMBERLYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 01/01/2024
- GILL, CHRISTOPHERIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 01/01/2024
- BENNETT, ADAMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- HUTTON, CHARLESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- KAUFFMAN, CLINTONIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- LEMAN, VALERIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- MCKAY, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- SMITH, JENNIFERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- WHITE, TAYLORIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- MALOTT, GREGGIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
- BRIARCLIFF HEALTH CARE - SOUTH BEND LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2024
- PULASKI MEMORIAL HOSPITALOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.26per resident day
RN hours0.39per resident day
Weekend nurse hours3.63per resident day
Staff turnover48.6%CMS reported field
06 / LOCAL RECORDS
Open the South Bend ledger →Other published facilities nearby
Cardinal Nursing And Rehabilitation Center144 beds · CMS overall 5/521 citation rowsHealthwin Health & Rehabilitation145 beds · CMS overall 2/578 citation rowsHoly Cross Rehabilitation And Wellness168 beds · CMS overall 2/547 citation rowsMajestic Care Of South Bend103 beds · CMS overall 1/599 citation rowsMilton Home, The34 beds · CMS overall 5/539 citation rowsSouthfield Village60 beds · CMS overall 3/550 citation rowsTrailpoint Village183 beds · CMS overall 2/554 citation rowsWellbrooke Of South Bend70 beds · CMS overall 4/543 citation rows