Comfort 1 Hospice, LLC
A hospice in Mishawaka, Indiana 46545
118 W Edison Road, Suite 200, Mishawaka, Indiana 46545. (574) 387-4117.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 7 deficiencies cited in the last three years
- Not rated family caregiver rating
- 8of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
7 deficiencies cited in the last three years
The middle of the 14 hospices serving ZIP code 46545 had 5.
The last inspection on record was on Oct 10, 2024: a reaccreditation inspection by the Accreditation Commission for Health Care.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
7 deficiencies in 1 month of the last 36. Last cited Oct 2024. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Oct 10, 2024: reaccreditation inspection by the Accreditation Commission for Health Care7 deficiencies
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 216 words
“Upon patient record review, 5 of 12 (Patients #2, 3, 4, 5, 9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: The patient is admitted with a primary diagnosis of heart disease. There is not interventions or goals included in the plan of care for cardiac. The plan of care does not include interventions or goals for use of oxygen. Patient #3: The patient is admitted for a primary diagnosis of senile degeneration of the brain. There are no interventions or goals for neuro. Patient #4: The patient is admitted with prostate cancer. There are no interventions or goals in the plan of care for cancer or GU. Patient #5: The patient is on oxygen and nebulized medication, though there is no interventions or goals for Respiratory. Patient #9: The patient is cognitively impaired and assessed as alert and oriented x 1. There is no plan of care that includes interventions or goals for cognitive impairment.”
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Content of plan of care (42 CFR 418.56(c)(5))
The inspectors’ words, 108 words
“Upon patient record review, 4 of 14 (Patient #1,2,3,8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: There were no supplies listed on the plan of care, including oxygen supplies. Patient #2: There were no supplies included on the plan of care, including oxygen supplies, wound care supplies, incontinence supplies, personal care supplies. Patient #3: There were no supplies included on the plan of care, including gloves, incontinence supplies, personal care supplies. Patient #8: There were no Foley supplies listed on plan of care.”
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Review of the plan of care (42 CFR 418.56(d))
“Upon client record review, 9 of 14 (Patient #1,2,3,6,8,10,11,13,14) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. The agency was without a Medical Social Worker for several months (2/2024 until 7/1/2024) There was no involvement in IDG from medical social work during that time.”
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Hospice aide assignments and duties (42 CFR 418.76(g)(1))
The inspectors’ words, 340 words
“Upon patient record review, 5 of 12 (Patients #1, 5, 6, 7, 8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: Aide plan of care did not include frequencies of tasks to be performed. This included haircare, oral care, and peri care. Patient #5: Aide plan of care task of Oxygen precautions did not include frequency of task to be performed. Task for lotion did not state where to apply lotion. Task for clean and file nails stated 1 time weekly and prn. The aide cannot determine the need for “prn” It must be specific. If the aide is seeing the patient more than once weekly, the tasks also must delineate which visit for any tasks not to be completed each visit. Patient #6: Aide plan of care task for clean and file nails was ordered 1 time weekly and prn. The aide cannot determine the need for “prn” It must be specific. Patient #7: Aide plan of care task for clean and file nails was ordered 1 time weekly and prn. The aide cannot determine the need for “prn” It must be specific. The task for monitoring fall precautions had no frequency. Patient #8: Aide plan of care did not list a frequency for assist with dressing or for empty Foley bag. The plan of care listed “new brief” as a care plan task with no explanation or frequency.”
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Role (42 CFR 418.78(b))
“Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. There is no evidence of use of volunteers for day to day administrative and/or direct patient care roles in 2024.”
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Level of activity (42 CFR 418.78(e))
“Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency has not met the 5% of the total patient care hours of all paid hospice employees and contract personnel for 2023 as it was 4.6%.”
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Content (42 CFR 418.104(a)(5))
“Upon patient client record review, 1 of 14 (Patient #2) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #2: The patient chose their attending physician. The initial certification including verbal order was received from the medical director. There is no proof of an initial certification written for the attending physician.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Oct 10, 2024 | Reaccreditation inspection by the Accreditation Commission for Health Care | 7 deficiencies cited |
| May 1, 2024 | Complaint inspection by the state | No deficiencies cited |
Is it certified?
- Medicare-certified hospice since Nov 6, 2018.
- Ownership: other.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 10.4 nurse care minutes per routine home care day, 3.7% of skilled nursing minutes at weekends and a visit near death for 81.6% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 82% at home, 1% in assisted living, 8% in a nursing facility, 9% in a skilled nursing facility.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 10.4 min |
| Skilled nursing minutes at weekends | 3.7% |
| Visits near death | 81.6% of patients who died |
Who owns it?
- Engleman Clinical Staffing LLC owns 17% directly since Dec 31, 2017.
- Zollal Investment LLC runs it.
- 5 owners or officers are people: Paul Chimutu (owns 5% or more directly, 17%); Paul Chimutu (managing employee (on the payroll), 17%); Motasem Afyouni (owns 5% or more directly, 17%); Jacqueline MD Mokfi (owns 5% or more directly, 17%); Matous Pradny (owns 5% or more directly, 17%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Zollal Investment LLC | Runs it (operational or managerial control) | 33% | Dec 31, 2017 |
| Engleman Clinical Staffing LLC | Owns 5% or more directly | 17% | Dec 31, 2017 |
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS’s Hospice Care Index: 8 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 25.81% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 33.3% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 8 of 10 |
How does it compare nearby?
- Of the 14 hospices CMS’s data show serving patients in ZIP code 46545, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 5; this one had 7.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| The Center for Hospice and Palliative Care Inc. | 5 |
| Southerncare South Bend | 28 |
| Heart to Heart Hospice of Northern Indiana LLC | 5 |
| Comfort 1 Hospice, LLC This hospice | 7 |
| Caring Cove Hospice LLC | 4 |
| Heartland Hospice (Ft Wayne) | 79 |
| Traditions Health | 2 |
| Elara Caring | 30 |
| Aseracare Hospice | 8 |
| Paradigm Health | 5 |
| Dunes Hospice LLC | 21 |
| Ascent Hospice LLC | 4 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.