Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Holy Cross Village At Notre Dame Inc during CMS and state inspections, most recent first.
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.
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 | — | 3 | 0 |
| Brickyard Healthcare - Fountainview Care Center | 2.5 mi | — | 3 | 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.