Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holy Cross Village At Notre Dame Inc during CMS and state inspections, most recent first.
The facility failed to timely update a care plan for a resident with MS, dementia, and protein calorie malnutrition after a new pressure ulcer was identified. The resident was severely cognitively impaired, dependent for bed mobility and transfers, incontinent of bowel and bladder, and had an unstageable pressure ulcer. Nursing notes showed the ulcer was documented before the care plan problem for the sacral pressure ulcer was initiated, and the ADON confirmed the delay.
Medication Administration Competency Failure: A QMA administered a resident's polyethylene glycol dissolved in water but left the medication at the bedside instead of ensuring the resident consumed it. The resident stated the clear liquid remained unfinished, and the QMA acknowledged she should have made sure the full dose was taken. The resident had an active order for daily polyethylene glycol, and the facility policy required observing resident consumption of medication.
The facility failed to monitor medications for two residents. One resident with DM had an ordered HA1C every 6 months, but the test was completed later than expected, and the ADON confirmed it should have been done earlier. Another resident with CHF, HTN, A-fib, edema, and depression had orders for furosemide and scheduled weights, but multiple weights were missed with no refusal documentation. The DON provided a medication administration policy, and no specific policy for weighing residents and notifying the provider of weight changes was available.
The facility failed to keep accurate EMR documentation for two residents. One resident with dementia and elopement risk was documented inconsistently after leaving through a window and being brought back by therapy staff, with the chart instead describing a different location. Another resident with multiple chronic conditions had a shower-related leg injury, but the record did not show that the husband called 911 or that the facility did not send her to the ED, leaving the note inaccurate.
An LPN administered a g-tube feeding to a resident on Enhanced Barrier Isolation while wearing gloves but not a gown. The resident had Parkinson’s disease, dysphagia, and a g-tube for nutrition and hydration. The LPN said she should have worn a gown but did not know where gowns were kept, despite having completed EBP training. The facility policy identified feeding tubes as a high-contact resident care activity requiring targeted gown and glove use.
A resident’s POA consented to pneumococcal vaccination, but the immunization was not given in a timely manner. The MAR showed the Prevenar 20 was spit out when scheduled and was not administered until much later, with the IP noting consented vaccinations should be completed within 30 days and that confusion occurred because the resident was on hospice and a QMA documented an error.
A resident did not receive a timely COVID-19 booster after POA consent was obtained, and two physician orders for the vaccine were not carried out as documented on the MAR. The IP stated consented vaccinations should be completed within 30 days and noted confusion because the resident was on hospice. A requested immunization policy was not provided before survey exit.
A resident with Multiple Sclerosis and other conditions was injured during a transfer when a CNA attempted to move her without a mechanical lift, contrary to the care plan. The resident's leg got caught on the bed rail, leading to a fall and a fracture. The incident was not immediately reported to management, and the resident's pain was initially managed with ibuprofen before an x-ray confirmed the fracture.
A facility failed to report an allegation of abuse involving a resident with multiple diagnoses, including dementia and heart failure. The DON received a note alleging a staff member pushed the resident out of bed, causing injury. Despite this, the facility did not substantiate or report the abuse, concluding it was gossip after consulting with lawyers. The facility's policy requires reporting such allegations within two hours if they involve abuse or serious injury.
The facility failed to ensure proper food safety and hygiene practices in the kitchen and pantry areas, including unclean utensils, improperly sealed food, expired items, and undated opened containers. The Regional Staff and LPN confirmed these issues should have been addressed according to facility policies.
The facility failed to update the care plan for a resident after discontinuing Ambien, despite the resident's multiple diagnoses and the facility's policy requiring regular care plan reviews. The DON confirmed the care plan should have been updated.
A resident who required extensive assistance and was incontinent developed pressure ulcers due to inadequate incontinence care. Despite care plans and facility policies aimed at preventing skin breakdown, the resident was not checked frequently enough, leading to the development of new pressure areas.
A facility failed to provide timely incontinent care for a resident with multiple diagnoses, including diabetes and chronic kidney disease. The resident, who required extensive assistance and was incontinent of bladder and bowel, was found with a saturated brief and open areas on his skin. The care plan required prompt incontinence care, but the resident indicated he was not checked until after lunch. The ADON confirmed the resident should have been checked more frequently.
The facility failed to ensure medication storage areas were free of expired medications and glucose testing solutions, and did not properly label medications with resident identifiers. Expired items and unlabeled medications were found on the Dujarie Unit, and a heavy build-up of ice was observed in the medication refrigerator. An LPN and the DON confirmed these deficiencies.
Delayed Care Plan Update for New Pressure Ulcer
Penalty
Summary
The facility failed to update a care plan timely for Resident 8 after a new pressure ulcer was identified. Resident 8 had diagnoses including multiple sclerosis, dementia, and protein calorie malnutrition, and a Quarterly MDS dated 3/23/2026 showed severe cognitive deficit, dependence for bed mobility and transfers, constant bowel and bladder incontinence, and an unstageable pressure ulcer. Nursing progress notes showed the pressure ulcer was first documented on 7/17/2025, but the care plan problem for a sacral pressure ulcer was not initiated until 8/25/2025. During interview, the ADON confirmed the pressure ulcer had first been identified on 7/17/2025 and that the care plan was not updated until 8/25/2025.
Medication Administration Competency Failure
Penalty
Summary
The facility failed to ensure that 1 of 2 nursing staff members observed, Qualified Medication Aide 2, demonstrated competence in administering medications. During an observation, Resident 6 stated that a cup of clear liquid at the bedside contained his polyethylene glycol laxative and that he had not finished taking it. During an interview shortly afterward, the QMA stated she had administered the resident's morning medications and had left the polyethylene glycol, which had been dissolved in water, at the bedside. She acknowledged that she should have ensured the resident took all of the medication before leaving the room. Record review showed Resident 6 had a physician's order for polyethylene glycol 17 grams by mouth dissolved in 4-8 ounces of fluid once daily, initiated on 12/17/2025. The facility's Medication Administration Policy, revised 8/2025, stated to observe resident consumption of medication.
Failure to Monitor Ordered Labs and Weights
Penalty
Summary
The facility failed to monitor medications for 2 of 6 residents whose records were reviewed. One resident had type 2 diabetes mellitus and was receiving daily insulin injections. The physician had ordered an HA1C test every 6 months, but the clinical record showed the HA1C was not completed until 3/20/2026. During interview, the ADON stated the HA1C should have been done on 2/12/2026 but was not completed until the later date. Another resident had diagnoses including chronic heart failure, hypertension, atrial fibrillation, localized edema of the lower extremities, osteoarthritis, bilateral hearing loss, nonrheumatic mitral valve insufficiency, and major depressive disorder. The resident had physician orders for furosemide and for weights to be obtained on Tuesdays and Fridays, with the physician to be notified if there was a 5-pound weight gain. Review of the TAR showed multiple missed weights in February and March 2026, and there was no documentation of weight refusal for those missed entries. The DON provided a medication administration policy that included reviewing the MAR and comparing the medication source with the MAR, and no specific policy regarding weighing residents and notifying the physician of weight changes was provided.
Inaccurate EMR Documentation of Resident Elopement and Injury Events
Penalty
Summary
The facility failed to ensure that the EMR contained accurate documentation of incidents involving two residents. For one resident, who had diagnoses including dementia, hypertension, glaucoma, and adjustment disorder with anxiety, the record showed an elopement risk score and a physician order for wanderguard checks every shift, but the documentation of an incident on 4/28/2026 did not match what staff later described. A nursing note stated the resident was found in a dining room area, while the DDC, DON, and therapy staff statements indicated the resident had removed window screens, pushed out a window, exited the building, and was observed outside on the facility grounds before being brought back inside by therapy staff. The EMR did not contain documentation of the resident’s exit from the building, and the record remained inaccurate when reviewed again later. For the second resident, who had diagnoses including chronic heart failure, hypertension, atrial fibrillation, localized edema, osteoarthritis, bilateral hearing loss, nonrheumatic mitral valve insufficiency, and major depressive disorder, the EMR did not accurately document the circumstances surrounding an injury during a shower. The husband reported that the resident was injured, had a hematoma on her right shin, was screaming in pain, and that he waited about thirty minutes after calling for help before calling 911 for an ambulance. Nursing documentation stated that a bottle of body wash fell onto the resident’s right shin causing a hematoma, ice was applied, and management was notified, but it did not include that the husband called 911 or that the facility did not send the resident out. Interviews with CNA and LPN staff showed the resident had complained of leg pain and that the LPN assessed the pain and left to notify the provider, but the chart still did not reflect the husband’s role in arranging the transfer. The DON stated the documentation did not accurately represent what happened and that someone reading the note would likely believe the facility sent the resident to the ED, when in fact the husband had called 911. The facility policy required each resident’s medical record to contain an accurate representation of actual experiences and for corrections to clarify inaccurate information, but the records for both residents remained inaccurate when reviewed again.
Failure to Maintain Enhanced Barrier Precautions During G-Tube Feeding
Penalty
Summary
Enhanced barrier precautions were not maintained during gastrostomy tube feeding administration for one resident. During an observation on 5/4/2026 at 9:50 A.M., an LPN administered a g-tube feeding while wearing gloves but not a gown, even though a sign on the resident’s room door indicated the resident was in Enhanced Barrier Isolation. During an interview shortly afterward, the LPN stated she should have worn a gown during the g-tube feeding administration but did not know where the gowns were kept and said she should have asked where they were stored. She also stated she had completed computer training on Enhanced Barrier Precautions. Record review showed the resident had diagnoses including Parkinson’s disease and dysphagia, had intact cognition, and had a g-tube for tube feedings. Physician orders included NPO status, additional water flushes via g-tube three times daily, and Jevity 1.5 bolus feedings via g-tube four times daily. The care plan indicated the need for g-tube feedings related to refusal to eat and swallow study results. The facility policy on Enhanced Barrier Precautions stated that EBP uses targeted gown and glove use during high-contact resident care activities, including device care or use such as feeding tubes.
Delayed Pneumococcal Vaccination After Consent
Penalty
Summary
The facility failed to provide a timely pneumococcal immunization for one resident reviewed for infection control. Record review showed the resident’s POA consented on 9/12/2025 for a pneumococcal vaccination and a COVID-19 booster to be administered. A physician’s order dated 3/30/2026 indicated Prevenar 20 was ordered for 4/8/2026, and another physician’s order dated 4/29/2026 again indicated Prevenar 20 for 4/29/2026. The MAR for 4/2026 showed the Prevenar 20 was spit out on 4/8/2026 and was not administered until 4/29/2026. During interview, the Infection Preventionist stated all consented vaccinations should be completed within 30 days of consent and said it would have been unusual for a vaccination not to be given until 5-6 months after consent. She also stated there had been confusion because the resident was receiving hospice services and the QMA documented an error when the Prevenar injection had been scheduled for 4/8/2026.
Delayed COVID-19 Vaccination Administration
Penalty
Summary
The facility failed to provide a timely COVID-19 immunization for 1 of 5 residents reviewed for infection control, Resident 29. The record showed the resident’s POA consented to the COVID-19 booster on 9/12/2025, and a physician’s order dated 3/30/2026 directed the COVID-19 mRNA vaccine to be given on 4/1/2026, but the April 2026 MAR showed it was not administered on that date. A later physician’s order dated 4/29/2026 directed the vaccine to be given on 5/1/2026, but the May 2026 MAR also showed it was not administered. During interview, the Infection Preventionist stated that all consented vaccinations should be completed within 30 days of consent and said it would have been unusual for a vaccination to be given 5-6 months after consent; she also stated there had been confusion about the resident’s COVID-19 vaccination because the resident was receiving hospice services. A requested COVID-19 immunization policy was not provided prior to survey exit.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff transferred a dependent resident using a mechanical lift in accordance with physician orders and the plan of care. The resident, who had diagnoses including Multiple Sclerosis, dementia, and seizures, was to be transferred with a mechanical lift and the assistance of two persons. However, during a transfer, the resident was lowered to the floor, resulting in a fall and a fracture of the left shin. The incident report did not indicate the failure to use a mechanical lift or identify the staff involved. The resident's care plan required the use of a mechanical lift with total assistance of two staff members for all transfers due to impaired balance and mobility. Despite this, a CNA attempted to transfer the resident alone without a mechanical lift, as a sling could not be found. The CNA attempted to transfer the resident by hugging her, which led to the resident's leg getting caught on the bed rail and being lowered to the floor. The incident was not immediately reported to facility management, and the resident's pain was initially managed with ibuprofen before an x-ray revealed a fracture. Interviews with staff revealed that there were no concerns about the availability of mechanical lift slings, as they could be found in the laundry or clean utility room. However, the CNA involved in the incident stated that the resident instructed her to proceed without the sling, as others had done before. The facility's policy required staff to maintain compliance with safe handling and transfer practices, and failure to do so could lead to disciplinary action. The incident highlighted a lapse in following the established care plan and communication protocols within the facility.
Removal Plan
- The facility interviewed all parties involved.
- Provided corrective actions.
- Education to ensure nursing staff would notify management of all incidents, whether there had been an injury or not.
- CNA's were educated to follow the plan of care.
- Results of education discussed in QAPI meeting.
- No other concerns regarding mechanical lifts had been observed or reported; however, observations continued to ensure resident safety.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident diagnosed with atrial fibrillation, dementia, cerebral infarction, and heart failure. On June 26, 2024, a record review revealed that the facility had received and investigated an allegation of physical abuse by a staff member towards the resident. The Director of Nursing (DON) received a note on May 30, 2024, indicating that a staff member had allegedly pushed the resident out of bed, causing the resident to hit her head. Despite this, the facility did not substantiate the abuse and chose not to report it. During interviews, the DON and Administrator stated that within two hours of receiving the allegation, they had conducted an investigation and concluded there was no abuse, consulting with their lawyers who also believed it was not abuse but rather gossip. They determined the allegation did not meet the criteria for elder abuse and did not require reporting. The facility's policy, dated March 31, 2022, mandates reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, particularly within two hours if the events involve abuse or result in serious bodily injury.
Food Safety and Hygiene Deficiencies in Kitchen and Pantry
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen and pantry areas. During an initial tour of the kitchen, several deficiencies were observed, including cooking utensils with dried food, a burnt spatula, a measuring cup with dried food, and microwaves with food debris. Additionally, cheese slices and a hunk of cheese were not sealed properly in a cooler, and several skillets had missing Teflon. The Regional Staff acknowledged these issues, indicating that the skillets should be discarded, utensils cleaned, and cheeses sealed properly. Furthermore, expired food items such as cottage cheese, lunch meat, and salad mix were found in the walk-in cooler, which the Regional Manager confirmed should have been discarded. In the Dujarie pantry, an opened and undated container of a yellow substance was found in the freezer, along with two opened and undated bottles of thick and easy. The refrigerator shelves and door compartments had food substances and dried liquids, and the microwave had a thick black film on its roof. The LPN confirmed that these items should have been cleaned and dated. The facility's policies on food and supply storage and cleaning of food and nonfood contact surfaces were provided, indicating the procedures that should have been followed to prevent these deficiencies.
Failure to Update Care Plan for Discontinued Medication
Penalty
Summary
The facility failed to revise the care plan for a resident who was prescribed anti-anxiety medication. The resident had multiple diagnoses, including hypertension, anxiety, depression, psychotic disorder, hemiplegia, and seizures. A quarterly MDS assessment indicated the resident received antipsychotics, antidepressants, and hypnotic medication. The care plan, dated 9/10/2022, indicated the use of Ambien for sleep issues, and another care plan, dated 11/14/2023, included interventions related to Ambien use. However, the Ambien was discontinued on 10/3/2023, and the care plan was not updated to reflect this change. The Director of Nursing confirmed that the care plan should have been updated. The facility's policy on comprehensive care planning, dated 12/2022, requires the care plan to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Failure to Prevent Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers for a resident who was cognitively intact and required extensive assistance for bed mobility, transfers, and toileting. The resident, who had a history of multiple pressure areas and was incontinent of bladder and bowel, developed three open areas on his buttocks while at the facility. Despite having care plans in place that included interventions such as providing incontinence care as soon as possible after an event and applying barrier cream, the resident's skin was often exposed to moisture, increasing the risk of pressure ulcers. Observations and interviews revealed that the resident was not checked for incontinence frequently enough. On one occasion, the resident was found sitting in a wheelchair with a saturated brief that had a strong smell of urine, indicating he had been sitting in the soaked brief since getting up in the morning. This lack of timely incontinence care contributed to the development of new pressure areas, including a deep tissue injury and stage 2 pressure ulcers. The facility's policy on pressure injury prevention emphasized minimizing exposure to moisture and keeping the skin clean, especially from fecal contamination. However, the resident's care did not align with these guidelines, as evidenced by the observations and interviews. The Assistant Director of Nursing acknowledged that the resident should have been checked more frequently for incontinence, highlighting a failure in adhering to the facility's protocols for preventing pressure ulcers.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident who was reviewed for urinary incontinence. Resident 9, who had diagnoses including diabetes, chronic kidney disease stage 3, bladder neck obstruction, and benign prostatic hyperplasia, was cognitively intact and required extensive assistance for bed mobility, transfers, and toileting. The resident was incontinent of bladder and bowel and had two stage 2 pressure areas. The care plan indicated that incontinence care should be provided as soon after an event as possible, including cleansing, application of barrier cream, and changing of briefs and clothing if needed. On the day of the observation, Resident 9 was seen in his wheelchair in the dining room and later in his room. During an interview, the resident indicated that he usually did not get checked for incontinence until he went to bed after lunch. Later, when the resident was transferred to his bed, his brief was found to be saturated with urine and had a strong smell. Open areas were observed on his gluteal folds and coccyx. CNA 6 confirmed that the resident had been changed in the morning but had been sitting in the soaked brief since then. The ADON acknowledged that the resident should have been checked more frequently for incontinence. The facility's incontinence policy indicated that all incontinent residents should receive appropriate treatment and services based on their comprehensive assessment.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medication storage areas were free of expired medications and glucose testing solutions, and did not properly label medications with resident identifiers. During an observation of the medication cart on the Dujarie Unit, several expired items were found, including antacid tablets, Vitamin D3 tablets, and glucose testing solution. Additionally, anti-diarrheal tablets, personal lubricant, and Vitamin D3 were found without resident identifiers. An LPN confirmed that these items were expired and should not have been in the medication cart, and that the medications should have had resident identifiers. In the medication storage room on the Dujarie Unit, a heavy build-up of ice was observed in the medication refrigerator. An LPN confirmed that the refrigerator should not have an ice build-up. The Director of Nursing provided the facility's current policies on medication storage and labeling, which indicated that all medications should be stored according to the manufacturer's recommendations and labeled in accordance with federal and state requirements. The policies also stated that expired medications should be identified and the nurse manager notified.
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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 Notre Dame
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Milton Home, The | 1 mi | ★★★★★ | 6 | 0 |
| Cardinal Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| Wellbrooke Of South Bend | 1.3 mi | ★★★★★ | 19 | 0 |
| Holy Cross Rehabilitation And Wellness | 2.2 mi | ★★★★★ | 5 | 0 |
| Brickyard Healthcare - Fountainview Care Center | 2.5 mi | ★★★★★ | 3 | 0 |
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