Holy Cross Village at Notre Dame Inc

In the surveyor’s words

From the most serious findings on record at Holy Cross Village at Notre Dame Inc, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 27, 2024

  Based on observation, record review and interview, the facility failed to ensure staff transferred a dependent resident with a mechanical lift in accordance with physician orders and the plan of care for 1 of 3 residents reviewed for mechanical lifts. (Resident E) This deficient practice resulted in a fall and the resident sustained a left shin fracture. The deficient practice was corrected on 7/31/2024, prior to the start of the survey, and was therefore past non-compliance. Finding includes: On 9/26/24 at 2:08 P.M., a review of the clinical record For Resident E was conducted. […]

• No harm, potential for more than minimal, widespreadF812Mar 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure food items in a cooler were sealed securely after opening, failed to have clean cooking utensils and skillets without missing Teflon, failed to ensure microwaves were clean and free of food debris, failed to remove expired foods, and failed to date foods when opened, in 1 of 1 kitchens and 1 of 3 pantries observed. This had the potential to affect the 47 of 48 residents who received meals from the kitchen. (Main Kitchen) Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF657May 6, 2026

  Based on record review and interview the facility failed to update a care plan timely for a resident that acquired a new pressure ulcer for 1 of 15 residents whose care plans were reviewed. (Resident 8)Finding includes:A record review was completed on 4/30/2026 at 2:01 P.M. for Resident 8. Diagnoses included, but were not limited to, multiple sclerosis, dementia and protein calorie malnutrition.A Quarterly Minimum Data Set (MDS) assessment, dated 3/23/2026, indicated Resident 8 had a severe cognitive deficit, was dependent for bed mobility and transfers, was always incontinent of bowel and bladder and had an unstageable pressure ulcer.Review of Nursing Progress Notes indicated a pressure ulcer was first documented on 7/17/2025.However, review of a Care Plan Problem for a sacral pressure… […]

• No harm, potential for more than minimal, isolatedF726May 6, 2026

  Based on observation, record review, and interview, the facility failed to ensure 1 of 2 nursing staff (Qualified Medication Aide 2) administering medications demonstrastrated competence.Finding includes:During an observation on 5/4/2026 at 9:50 A.M., Resident 6 indicated a cup of clear liquid sitting at the bedside contained his laxative (polyethylene glycol) that he had not finished yet. During an interview on 5/4/2026 at 10:09 A.M., Qualified Medication [NAME] (QMA) 2 indicated she had administered morning medications to Resident 6 and had left the polyethylene glycol medication, which had been dissolved in water, at his bedside. […]

• No harm, potential for more than minimal, isolatedF757May 6, 2026

  Based on record review and interview the facility failed to monitor medications for 2 of 6 residents whose medications were reviewed. (Residents 4 and 1)1. A record review was completed on 5/1/2026 at 9:01 A.M. for Resident 4. Diagnoses included, but were not limited to type 2 diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, dated 3/17/2026, indicated Resident 4 received daily insulin injections. Physician Orders included, but were not limited to, the following: -dated 4/6/2026 Insulin Glargine Subcutaneous Solution Pen-injector 100 units/milliliter inject 20 units subcutaneously in the evening for diabetes mellitus. -dated 8/12/2025 HA1C (glycated hemoglobin test- a blood test that measures average blood sugar levels over the past 2-3 months) every 6 months. […]