Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southfield Village during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in the kitchen, with a container of pickles stored without a secure lid in the walk-in cooler and dirty utensils found in the clean utensils drawer. The Director of Food Services acknowledged these issues, which were contrary to the facility's policy requiring weekly spot checks for compliance.
The facility failed to notify physicians of elevated blood glucose levels for two residents with type 2 diabetes, as required by physician orders. Resident 7 had multiple instances of elevated levels without documentation of physician notification, confirmed by the DON. Similarly, Resident 3's elevated levels were not reported, as indicated by the MAR and interviews with the DON and an LPN. The facility's policy required timely reporting of critical test results, which was not followed.
The facility failed to provide a Bed Hold Policy to a resident transferred to the hospital with conditions including Alzheimer's and COPD. Despite issuing a Notice of Transfer/Discharge, there was no documentation of the Bed Hold Policy being given. An employee confirmed its absence in the chart, and the MDS Nurse later provided the policy, but the facility lacked guidance on when to issue it.
The facility failed to conduct quarterly Care Plan meetings with two residents and/or their representatives. One resident, with intact cognition and multiple health issues, reported not being invited to meetings, and her records lacked documentation of such meetings. Another resident, with severe cognitive impairment, also had no documented Care Plan meetings. The Social Services Director confirmed that meetings should have occurred, as per the facility's policy.
The facility failed to follow infection control practices in two incidents. A housekeeper cleaned a resident's room under contact precautions for Clostridium difficile without wearing a gown, misunderstanding the signage. Additionally, a CNA did not change gloves or use a clean washcloth during catheter care for a resident with a Foley catheter. Both staff members later acknowledged their errors.
Sanitation Deficiencies in Kitchen Storage and Utensil Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, specifically in the storage and handling of food and utensils. During an initial kitchen tour, it was observed that a container of pickles in the walk-in cooler was stored without a secure lid, leaving it open to air. The Director of Food Services acknowledged that the lid should have been secured. In a follow-up kitchen tour, it was found that a metal scoop and a pair of metal tongs with dried food on them were stored in the clean utensils drawer, which also contained dried food and other debris at the bottom. The Director of Food Services confirmed that utensils should be clean before being placed in the drawers and that the utensil drawer should have been cleaned. The facility's policy required weekly spot checks of refrigerators for compliance, but these deficiencies were still present.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of elevated blood glucose levels for two residents with type 2 diabetes, leading to a deficiency. For Resident 7, the physician's order required notification if blood glucose levels were below 70 or above 200 mg/dL. However, the facility did not document any notification to the physician for multiple instances of elevated blood glucose levels ranging from 210 mg/dL to 319 mg/dL over the months of August, September, and October 2024. The Director of Nursing (DON) confirmed that the electronic medication administration record (EMAR) lacked documentation of physician notification, which should have been recorded. Similarly, for Resident 3, the physician's order required notification for blood glucose levels less than 70 or greater than 200 mg/dL. The Medication Administration Record (MAR) showed elevated blood glucose levels on several occasions in September and October 2024, with no documentation of physician notification. Interviews with the DON and LPN 6 revealed that such notifications should have been documented in the nursing progress notes or associated with the order in the MAR. The facility's policy on blood glucose monitoring required timely reporting of critical test results to the physician, which was not adhered to in these cases.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to a resident when they were admitted to the hospital. This deficiency was identified during a review of Resident 4's records, who had diagnoses including Alzheimer's Disease, chronic obstructive pulmonary disease, and atrial fibrillation. On 9/7/2024, Resident 4 experienced shortness of breath and confusion, leading to a hospital transfer for suspected pneumonia. Although the Notice of Transfer/Discharge was documented, there was no evidence that the Bed Hold Policy was provided to the resident. An interview with Employee 6 confirmed the absence of the Bed Hold Policy in the resident's chart. The MDS Nurse later provided a copy of the policy that should have been given, but the facility lacked a policy indicating when this document should be provided.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct Care Plan meetings quarterly with residents and/or their representatives, as required. Resident 6, who has diagnoses including chronic obstructive pulmonary disease, hemiplegia, dysphagia, aphasia, vascular dementia, and emphysema, reported not being invited to Care Plan meetings. Her record showed no documentation of such meetings from November 2023 through May 2024, despite having an intact cognition and receiving a Quarterly Minimum Data Set (MDS) assessment in September 2024. The Social Services Director (SSD) confirmed that a Care Plan meeting should have occurred after her MDS assessment in January 2024. Similarly, Resident 7's representative could not recall being invited to a Care Planning meeting. Resident 7, who has severe cognitive impairment and diagnoses including type 2 diabetes mellitus, sick sinus syndrome, cardiomegaly, and adjustment disorder, also lacked documentation of Care Plan meetings between November 2023 and April 2024. The SSD acknowledged that a meeting should have been conducted during this period. The facility's policy, dated January 2024, mandates Care Plan meetings every three months or when there is a significant change in a resident's health status.
Infection Control Lapses in Isolation Room Cleaning and Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices as observed in two separate incidents involving staff members. In the first incident, a housekeeper was observed cleaning the room of a resident on contact precautions due to Clostridium difficile without wearing a gown, as required. The housekeeper misunderstood the signage indicating contact precautions and did not recall receiving training on the differences between contact precautions and enhanced barrier precautions. The Assistant Director of Nursing (ADON) confirmed that the housekeeper should have donned a gown before entering the room. The resident in question had a positive Clostridium difficile result and was under specific isolation orders. In the second incident, a CNA was observed providing catheter care to a resident with an indwelling Foley catheter without changing gloves or using a clean washcloth between cleaning different areas. The CNA initially did not recognize any wrongdoing but later acknowledged the need to change gloves and use a clean washcloth. The facility's policies on isolation precautions and catheter care were reviewed, indicating the need for adherence to specific procedures to prevent infection transmission.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near South Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trailpoint Village | 2.7 mi | — | 18 | 0 |
| Brickyard Healthcare - Twelfth Street Care Center | 4.5 mi | — | 29 | 0 |
| Cardinal Nursing And Rehabilitation Center | 4.9 mi | — | 0 | 0 |
| Milton Home, The | 5.2 mi | — | 6 | 0 |
| Holy Cross Village At Notre Dame Inc | 6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.