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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Lodged within the picturesque South Bend, Indiana, Southfield Village Inc. occupies an idyllic location within a tranquil and perfectly positioned neighborhood. Exuding an undeniable familial charm, this community is surrounded by a thriving downtown area, a vibrant cultural arts scene, and resplendent gardens that contribute to its captivating allure.
Residents are treated to culinary delights curated by an award-winning chef, enhancing their dining experiences. The offerings extend beyond delectable meals, encompassing a variety of amenities such as a playground, a well-stocked library, meticulously tended resident gardens, and access to a lush forest preserve. Engaging academic classes and captivating local attraction tours further enrich the vibrant tapestry of experiences at Southfield Village Inc. Practical indulgences in the form of beauty and barber services harmonize with the community’s commitment to holistic wellbeing, strengthened by the presence of a fitness center.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 49th out of 267 homes in Indiana.| Staff type | Hours / day | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 1h 8m per day | ▲ 70% State avg: 40m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 29m per day | ▼ 37% State avg: 46m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 34m per day | ▲ 13% State avg: 2h 16m per day · National avg: 2h 20m per day |
|
Total Nursing (Weekend)
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 38m per day | ▲ 12% State avg: 3h 14m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 3m per day | ▼ 25% State avg: 4m per day · National avg: 4m per day |
|
RN (Weekend)
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 48m per day | ▲ 78% State avg: 27m per day · National avg: 28m per day |
Most residents typically stay for a few weeks or months before returning home or moving on.
54% of new residents, usually for short-term rehab.
42% of new residents, often for short stays.
4% of new residents, often for long-term daily care.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #171 / 267Payroll — state benchmarkedThis home is ranked 171st out of 267 homes in Indiana.Shows total annual staff payroll benchmarked to the Indiana average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Lower than the Indiana average: 68.1%Southfield Village Inc. is legally operated by Woodlawn Hospital, and administrated by Joseph Doran.
Key information about the people who lead and staff this community.
Pets Allowed
Building Type: Two-story
Transportation Services
Fitness and Recreation
In Indiana, the Department of Health, Division of Long Term Care is the primary regulatory body that performs onsite inspections and quality of care reviews for all licensed facilities.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Indiana state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies are formal regulatory issues recorded during state inspections.
| Metric | This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 56 | 36 | This facility has 56% more total deficiencies than a typical Indiana assisted living residence (56 vs. IN avg 36).↑ 56% worse |
|
Deficiencies per year
Average deficiencies per year since 2022.
| 14 | 9 | This facility has 56% more deficiencies per year than a typical Indiana assisted living residence (14 vs. IN avg 9).↑ 56% worse |
|
Deficiencies per inspection
Average deficiencies per inspection.
| 2.8 | 1.9 | This facility has 47% more deficiencies per inspection than a typical Indiana assisted living residence (2.8 vs. IN avg 1.9).↑ 47% worse |
State inspections evaluate whether the facility meets health and safety standards.
| Metric | This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total visits
Combined count of all on-site visits — routine inspections, complaint visits, follow-ups, and other focused visits.
| 20 | 19 | This facility has 5% more total visits than a typical Indiana assisted living residence (20 vs. IN avg 19).↑ 5% worse |
|
Inspections with deficiencies
Inspections that resulted in at least one regulatory deficiency.
| 8 | 7 | This facility has 14% more inspections with deficiencies than a typical Indiana assisted living residence (8 vs. IN avg 7).↑ 14% worse |
|
Inspection deficiency rate
Percentage of inspections that resulted in at least one deficiency.
| 40% | 37% | This facility has 3 percentage points higher inspection deficiency rate than a typical Indiana assisted living residence (40% vs. IN avg 37%).↑ 3% worse |
|
Inspections
Routine, scheduled inspections conducted by state regulators.
| 10 | 13 | This facility has 23% fewer inspections than a typical Indiana assisted living residence (10 vs. IN avg 13).↓ 23% better |
Complaints are formal concerns filed by residents, families, or staff. Investigations are on-site follow-ups.
| Metric | This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total complaints
Formal expressions of concern made by residents, families, or staff.
| 4 | 5 | This facility has 20% fewer total complaints than a typical Indiana assisted living residence (4 vs. IN avg 5).↓ 20% better |
|
Complaints per year
Average complaints per year since 2022.
| 1 | 1.3 | This facility has 23% fewer complaints per year than a typical Indiana assisted living residence (1 vs. IN avg 1.3).↓ 23% better |
|
Complaint visits
On-site visits triggered by formal complaints. Formal complaints can result in multiple visits.
| 10 | 8 | This facility has 25% more complaint visits than a typical Indiana assisted living residence (10 vs. IN avg 8).↑ 25% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
The most recent inspection on March 12, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving emergency preparedness, life safety code compliance, resident care including medication management, infection control, and care planning. Complaint investigations were mostly unsubstantiated, except for one substantiated complaint in November 2022 related to wound care and supervision that led to elopement. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent inspections indicate improvement, with the latest surveys showing compliance following prior citations.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsIndiana average 6
Last Health inspection on Oct 2024
Indiana average 25
Indiana average 4.12
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
All 24 citations resulted from standard inspections.
100% better than Indiana averageIndiana average: 0.2
0
100% better than Indiana averageIndiana average: 0.6
Issues related to preventing and controlling infections, including hygiene practices and safety protocols.
Oct 31, 2024
Corrected
Issues related to food quality, meal service, and resident's nutritional needs.
Oct 31, 2024
Corrected
Issues related to creating and updating personalized care plans for residents based on their needs and conditions.
Oct 31, 2024
Corrected
Issues related to resident's rights, including dignity, privacy, and the ability to make decisions about their care.
Oct 31, 2024
Corrected
Data sourced from CMS Health Deficiencies reports. Citation severity codes range from A (least serious) to L (most serious). Immediate Jeopardy (J-L) citations indicate situations where the facility's noncompliance has placed residents at risk of death or serious harm.
Southfield Village Inc. is located in South Bend, Indiana.
Here are the financial assistance programs available to residents in Indiana.
5.7 miles from city center
Estimated distance in miles from South Bend's city center to Southfield Village Inc.'s address, calculated via Google Maps.
— 1.48 miles to nearest hospital (Vet Center South Bend)
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This data corresponds to Q2 2025 and is based on CMS Payroll-Based Journal.
2282919% better than Indiana averageIndiana average ratio: 0.00:1
0% compared with Indiana averageIndiana average: 7.7 hours
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.5 hoursThis role is partially covered by contractors.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
11 hoursThis role is partially covered by contractors.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.5 hoursThis role is partially covered by contractors.
Total hours from contractors
7,098 contractor hours this quarter
| Certified Nursing Assistant | 30 | 20 | 50 | 10,352 | 91 | 100% | 7.5 |
| Registered Nurse | 6 | 10 | 16 | 3,313 | 91 | 100% | 9.5 |
| Licensed Practical Nurse | 2 | 13 | 15 | 2,276 | 90 | 99% | 11 |
| Clinical Nurse Specialist | 2 | 0 | 2 | 1,005 | 70 | 77% | 8.3 |
| Other Dietary Services Staff | 3 | 0 | 3 | 761 | 75 | 82% | 6 |
| Speech Language Pathologist | 0 | 4 | 4 | 734 | 67 | 74% | 4.5 |
| Medication Aide/Technician | 3 | 3 | 6 | 728 | 58 | 64% | 8.9 |
| Physical Therapy Aide | 0 | 6 | 6 | 581 | 71 | 78% | 4.3 |
| Dietitian | 1 | 0 | 1 | 504 | 63 | 69% | 8 |
| Mental Health Service Worker | 1 | 1 | 2 | 490 | 55 | 60% | 8.6 |
| Administrator | 1 | 0 | 1 | 488 | 61 | 67% | 8 |
| Nurse Practitioner | 1 | 0 | 1 | 469 | 48 | 53% | 9.8 |
| Respiratory Therapy Technician | 0 | 3 | 3 | 185 | 38 | 42% | 4.5 |
| Physical Therapy Assistant | 0 | 5 | 5 | 140 | 56 | 62% | 2.2 |
| Occupational Therapy Aide | 0 | 1 | 1 | 104 | 13 | 14% | 8 |
| Medical Director | 0 | 1 | 1 | 39 | 26 | 29% | 1.5 |
| Occupational Therapy Assistant | 0 | 2 | 2 | 26 | 11 | 12% | 2.4 |
| Qualified Social Worker | 0 | 2 | 2 | 21 | 18 | 20% | 1.2 |
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
53Residents meet regularly to discuss policies, care quality, and activities
Part of a Continuing Care Retirement Community offering multiple care levels
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
11.0
37% worse than Indiana averageIndiana average: 8.0
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
24.8
45% worse than Indiana averageIndiana average: 17.1
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
25.2%
109% worse than Indiana averageIndiana average: 12.0%
Percent of long-stay residents whose ability to move independently worsened
22.1%
54% worse than Indiana averageIndiana average: 14.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
27.0%
10% worse than Indiana averageIndiana average: 24.6%
Percent of long-stay residents experiencing one or more falls with major injury
1.9%
52% better than Indiana averageIndiana average: 3.9%
Percent of long-stay high risk residents with pressure ulcers
1.3%
70% better than Indiana averageIndiana average: 4.4%
Percent of long-stay residents with a urinary tract infection
0.6%
49% better than Indiana averageIndiana average: 1.2%
Percent of long-stay residents who lose too much weight
4.4%
22% better than Indiana averageIndiana average: 5.7%
Percent of long-stay residents who have depressive symptoms
1.3%
95% better than Indiana averageIndiana average: 24.1%
Percent of long-stay residents who received an antipsychotic medication
3.1%
75% better than Indiana averageIndiana average: 12.4%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
84.6%
10% worse than Indiana averageIndiana average: 93.7%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
97.7%
In line with Indiana averageIndiana average: 95.4%
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
94.3%
15% better than Indiana averageIndiana average: 81.7%
Percent of short-stay residents who newly received an antipsychotic medication
0.0%
100% better than Indiana averageIndiana average: 1.4%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
83.1%
5% better than Indiana averageIndiana average: 79.0%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
23.2%
In line with Indiana averageIndiana average: 22.4%
Percentage of short-stay residents who had an outpatient emergency department visit.
10.7%
In line with Indiana averageIndiana average: 10.5%
Percentage of SNF residents who experience falls with major injury during their stay.
0.0%
100% better than Indiana averageIndiana average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
68.0%
27% better than Indiana averageIndiana average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
51.0%
In line with Indiana averageIndiana average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
The information below is reported by the Indiana Department of Health, Division of Long Term Care.
| St Paul’s |
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | South Bend | 181 | No | 0 | - | 1 | 54.1% | Jeffry Billhimer | Trinity Continuing Care Services-Indiana Inc | Kris Borkowski | 5 | 1 | 8 | 1.6 |
| Southfield Village Inc. |
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care). | South Bend | 138 | Yes | 5 | - | 34 | 34.1% | Joseph Doran | Woodlawn Hospital | Dolores Britton | 20 | 4 | 56 | 2.8 |
| Grand Emerald Place |
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | South Bend | 96 | Yes | 36 | - | 13 | 51.0% | Amanda Harlow | Ops Living South Bend LLC | Lindsay Vanderpool | 12 | 5 | 27 | 2.3 |
| Brookdale South Bend |
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | South Bend (Clay) | - | Yes | 28 | - | - | - | - | - | - | - | - | - | - |
| Helping Angels Care |
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | South Bend (Swanson Highlands) | - | No | 14 | - | - | - | - | - | - | - | - | - | - |
Historical financial and operational data for Southfield Village Inc. based on CMS SNF Cost Reports.
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Dolores Britton is the Director of Nursing at Southfield Village Inc..
The legal owner and operator of Southfield Village Inc. is Woodlawn Hospital.
Southfield Village Inc. has a walk score of 5. Car-dependent. Most errands require a car, with limited nearby walkable options.
According to IN state health department records, Southfield Village Inc.'s license number is 24-002662-1.
According to IN state health department records, Southfield Village Inc.'s license expires on October 31, 2025.
Southfield Village Inc.'s occupancy is 34%.
Joseph Doran is the administrator of Southfield Village Inc..
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