Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

HOLY CROSS VILLAGE AT NOTRE DAME INC

NOTRE DAME, IN · 52 certified beds · Last Life Safety survey May 6, 2026

CMS Certification Number 155745 · first certified January 2006

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

20
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
8
Inspection & testing records
Of the citations on file

Position within IN

20 citations — more than 66% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 13 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens April 2027 — about 7 months from now. This facility’s last Life Safety survey was May 2026. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

3 of the 20 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.

This facility20IN median15National median11
Citations on file over three years, compared
MeasureCitations
This facility20
Median facility in IN15
Median facility nationally11

Survey history

Citations at each Life Safety survey
42024-0332025-03132026-05
Citations at each Life Safety survey
Survey dateCitations
March 25, 20244
March 13, 20253
May 6, 202613

Most-cited tags

Most-cited tags at this facility
K-05112K-03512K-03532E-00411K-09211K-09271K-03451K-03721
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0511Have properly installed electrical wiring and gas equipment.22026-05-06
K-0351Install an approved automatic sprinkler system.22026-05-06
K-0353Inspect, test, and maintain automatic sprinkler systems.22026-05-06
E-0041Implement emergency and standby power systems.12026-05-06
K-0921Ensure that testing and maintenance of electrical equipment is performed.12026-05-06
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.12026-05-06
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12026-05-06
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.12025-03-13

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 7
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Emergency Preparedness Deficiencies 3
  • Egress Deficiencies 3
  • Other 3
Citations by CMS category
CategoryCitations
Smoke Deficiencies7
Gas, Vacuum, and Electrical Systems Deficiencies4
Emergency Preparedness Deficiencies3
Egress Deficiencies3
Services Deficiencies2
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

May 6, 2026 — 13 citations

Citations issued on May 6, 2026
TagWhat the surveyor checksStatus
E-0037Establish staff and initial training requirements.Deficient, Provider has plan of correction (July 31, 2026)
E-0039Conduct testing and exercise requirements.Deficient, Provider has plan of correction (July 31, 2026)
E-0041Implement emergency and standby power systems.Deficient, Provider has plan of correction (July 31, 2026)
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.Deficient, Provider has plan of correction (June 10, 2026)
K-0281Install proper backup exit lighting.Deficient, Provider has plan of correction (June 12, 2026)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has plan of correction (June 8, 2026)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has plan of correction (June 15, 2026)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has plan of correction (July 10, 2026)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has plan of correction (June 8, 2026)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has plan of correction (June 11, 2026)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has plan of correction (June 8, 2026)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has plan of correction (July 31, 2026)
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.Deficient, Provider has plan of correction (June 8, 2026)

March 13, 2025 — 3 citations

Citations issued on March 13, 2025
TagWhat the surveyor checksStatus
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.Deficient, Provider has date of correction (May 4, 2025)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (May 4, 2025)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (May 4, 2025)

March 25, 2024 — 4 citations

Citations issued on March 25, 2024
TagWhat the surveyor checksStatus
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (May 9, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 9, 2024)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (May 9, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (May 9, 2024)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.