Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HOLY CROSS REHABILITATION AND WELLNESS
SOUTH BEND, IN · 168 certified beds · Last Life Safety survey April 28, 2025
CMS Certification Number 155506 · first certified January 1994
Ownership
Operated by TRINITY HEALTH · Non profit - Other
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IN
21 citations — more than 68% 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
The latest survey found 13 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (April 2026 to June 2026), and past the point by which nine in ten IN facilities have been surveyed. This facility’s last Life Safety survey was April 2025. 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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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
6 of the 21 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)
6 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 21 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 21 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 23, 2023 | 5 |
| May 21, 2024 | 3 |
| April 28, 2025 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-04-28 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-04-28 |
| E-0041 | Implement emergency and standby power systems. | 2 | 2025-04-28 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-05-21 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2025-04-28 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2025-04-28 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-04-28 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 1 | 2025-04-28 |
What the citations cover
- Emergency Preparedness Deficiencies 6
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 6 |
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 28, 2025 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (July 22, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (August 16, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 15, 2025) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (July 22, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 22, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 22, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 22, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 22, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 22, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 22, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 22, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has plan of correction (July 6, 2025) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (July 22, 2025) |
May 21, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 22, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 22, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 22, 2024) |
May 23, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 14, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.