Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BRIARCLIFF HEALTH & REHABILITATION CENTER
SOUTH BEND, IN · 131 certified beds · Last Life Safety survey September 17, 2025
CMS Certification Number 155831 · first certified May 2015
Ownership
Operated by STERLING HEALTHCARE · Non profit - Other
- Ownership changed January 1, 2024 (change of ownership)from DECATUR COUNTY MEMORIAL HOSPITAL
Position within IN
32 citations — more than 89% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 10.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to November 2026. This facility’s last Life Safety survey was September 2025. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 32 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 32 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 32 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 14, 2023 | 11 |
| August 12, 2024 | 6 |
| August 8, 2025 | 14 |
| September 17, 2025 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-08-08 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2025-08-08 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 2 | 2025-08-08 |
| E-0041 | Implement emergency and standby power systems. | 2 | 2024-08-12 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2025-08-08 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-08-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-08-08 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2023-07-14 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Egress Deficiencies 6
- Miscellaneous Deficiencies 3
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Egress Deficiencies | 6 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 17, 2025 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (November 30, 2025) |
August 8, 2025 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (October 4, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 26, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 4, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Deficient, Provider has date of correction (October 4, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 4, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 4, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 4, 2025) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (September 26, 2025) |
August 12, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (September 12, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 6, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 27, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 12, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 27, 2024) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (September 27, 2024) |
July 14, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 31, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.