Cycle 1
Health 2025-03-13 · Fire 2025-03-13
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Notre Dame, IN
Holy Cross Village At Notre Dame Inc
5-star overall rating with 4-star inspections with 3 fire-safety deficiencies in the latest cycle
54515 State Road 933 North, Notre Dame, IN
(574) 287-1838
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-01-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
3.22
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.95
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.44
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,737
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.26% · Performance 22.75% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.28
Baseline 5.10% · Performance 7.45% · Measure score 1.28 · Achievement 1.28 · Improvement 0
Total nurse turnover
7.11
Baseline 37.50% · Performance 34.62% · Measure score 7.11 · Achievement 7.11 · Improvement 1.78
Adjusted total nurse staffing
5.68
Baseline 5.37 hours · Performance 4.69 hours · Measure score 5.68 · Achievement 5.68 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.97% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 162 · Observed rate 8.64% · Lower 95% interval 8.39% |
| Discharge to community | 48.88% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 154 · Observed rate 48.05% · Lower 95% interval 42.58% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.59% |
95.27%
2.7 pts worse
|
Numerator 75 · Denominator 81 |
| Falls with major injury | 3.7% |
0.77%
2.9 pts worse
|
Numerator 3 · Denominator 81 |
| Discharge self-care score | 42.42% |
53.69%
11.3 pts worse
|
Numerator 28 · Denominator 66 |
| Discharge mobility score | 60.61% |
50.94%
9.7 pts better
|
Numerator 40 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 11.11% |
2.29%
8.8 pts worse
|
Numerator 9 · Denominator 81 · Adjusted rate 11.6% |
| Healthcare-associated infections requiring hospitalization | 7.45% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 6.25% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 5.63% |
8.2%
2.6 pts worse
|
Numerator 4 · Denominator 71 |
| Staff flu vaccination coverage | 97.59% |
42%
55.6 pts better
|
Numerator 162 · Denominator 166 |
| Discharge function score | 48.48% |
56.45%
8 pts worse
|
Numerator 32 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 65.85% |
25.2%
40.6 pts better
|
Numerator 27 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.3 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
93.6%
5 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.1% · Q4 97.2% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.2% |
3.8%
4.4 pts worse
|
3.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.7% · Q3 11.8% · Q4 5.6% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
24.6%
23.9 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.6%
1.6 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.0% · Q3 0.0% · Q4 7.1% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
23.5%
9.9 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 15.4% · Q3 15.4% · Q4 10.7% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.4% |
14.8%
12.4 pts better
|
16.7%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.8% · Q4 4.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.6% |
13.3%
13.3 pts worse
|
16.3%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.6% |
11.7%
20.9 pts worse
|
14.9%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.9% · Q2 20.8% · Q3 37.5% · Q4 32.0% · 4Q avg 32.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.4%
0.6 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
1.2%
3.7 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.9% · Q3 0.0% · Q4 5.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.6% |
24.2%
7.4 pts worse
|
19.8%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 19.9% · Q3 40.9% · Q4 33.7% · 4Q avg 31.6% |
| Percentage of long-stay residents with pressure ulcers | 10.1% |
4.1%
6 pts worse
|
5.1%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.1% · Q3 4.3% · Q4 13.2% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
81.6%
9.9 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 84.4% · Q3 95.5% · Q4 94.1% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
10.5%
1 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 9.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.9% |
79.0%
13.9 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.0% |
22.4%
8.6 pts worse
|
23.9%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.0% · Observed 28.7% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-25 · Fire 2024-03-25
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-27 · Fire 2023-02-27
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-13
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-05-04
E · Potential for more than minimal harm
2025-03-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-04
E · Potential for more than minimal harm
2025-03-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-04
F · Potential for more than minimal harm
2024-03-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-03-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-03-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-03-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-09
F · Potential for more than minimal harm
2023-02-27
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-02-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-02-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-02-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-15
Inspection history
Recent health citations
G · Actual harm
2024-09-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-03-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-13
D · Potential for more than minimal harm
2024-03-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-13
D · Potential for more than minimal harm
2024-03-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-13
D · Potential for more than minimal harm
2024-03-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-18
D · Potential for more than minimal harm
2024-03-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-13
D · Potential for more than minimal harm
2023-02-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-19
Penalties and ownership
What sits behind the stars
Ownership
Holy Cross Village At Notre Dame, Inc.
5% Or Greater Direct Ownership Interest · Organization
Beauchamp, Edward
Corporate Director · Individual
Cholis, Paul
Corporate Director · Individual
Freel, Chester
Corporate Director · Individual
Freel, Chester
Corporate Officer · Individual
Haders, Csc, Ken
Corporate Director · Individual
Huge, Elizabeth
Corporate Officer · Individual
Kastner, Brandon
Corporate Officer · Individual
Lackenmier, Csc, James
Corporate Director · Individual
Lackenmier, Csc, James
Corporate Officer · Individual
Mueller, Jack
Operational/Managerial Control · Individual
Mueller, Jack
Corporate Officer · Individual
Neff, Mark
Corporate Director · Individual
Neff, Mark
Corporate Officer · Individual
Paskiewicz, Linda
Corporate Director · Individual
Paskiewicz, Linda
Corporate Officer · Individual
Place, Andrew
Corporate Director · Individual
Shakour, Michelle
Corporate Director · Individual
Tingwald, S.
Corporate Director · Individual
Nearby options
Other facilities in reach
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Wellbrooke Of South Bend
South Bend, IN
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Milton Home, The
South Bend, IN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Cardinal Nursing And Rehabilitation Center
South Bend, IN
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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