Indiana State Department of Health
Division of Long Term Care
 
CONSUMER REPORT
 
HOLY CROSS VILLAGE AT NOTRE DAME INC
 
NURSING HOME
SKILLED NURSING FACILITY / NURSING FACILITY DISTINCT PART
Created on: 07/25/2025
 
Posted to the Web on: 08/06/2025
 
 



Basic Information

FACILITY CONTACT INFORMATION:
Address: 54515 STATE ROAD 933 NORTH
City: NOTRE DAME
Telephone: (574) 287-1838
Web Site:  
 
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
 
LICENSE INFORMATION:
  License number: 25-002668-1
  License effective date: 07/01/2025
  License expiration date: 06/30/2026
 


Administration and Staff

Administrator: JACK MUELLER
  Start date: 06/14/2021
 
Director of Nursing: JENNIFER ARMENDARIZ
  Start date: 07/06/2021
 
Medical director: Thomas Sutula
  Start date:   /  /  
 
Wound care specialist:  
  Start date:   /  /  
 
Infection preventionist:  
  Start date:   /  /  
 


Ownership

CURENT OWNERSHIP:
 
Owning corporation: HOLY CROSS VILLAGE AT NOTRE DAME INC
200 RIVER RIDGE DRIVER
NOTRE DAME IN 46556
 
Ownership type:  NON-PROFIT
 
Officer(s): LAWRENCE SITISKI
            HAROLD EHLINGER
            LINDA PASKIEWICZ
            SHARON KEANE
            JAMES LACKENMIER
            MARK NEFF
            KEN HADERS
            CHAD TOWNER
            CHESTER FREEL
 
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: N/A
Date of last change of ownership: N/A
 


Bed Counts and Census

COMPREHENSIVE CARE BEDS:
Number of Medicaid beds (NF):                     0
Number of Medicare beds (SNF):                    22
Number of Medicare/Medicaid beds (SNF/NF):        30
Number of non-certified comprehensive care beds (State Licensed only):     0
Total number of comprehensive care beds:     52
 
RESIDENTIAL CARE BEDS:
 
Total number of residential beds:            76
 
Total number of beds in facility:            128
 
CENSUS:
Facility census:  86
As reported by the facility on: 01/18/2023
 
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 01/18/2023
 
Residential care beds occupied:  40
As reported by the facility on: 01/18/2023
 
Alzheimer Beds:  12
Alzheimer Beds Occupied:  11
As reported by the facility on:   /  /  
 
Ventilator Beds:  0
Ventilator Beds Occupied:  0
As reported by the facility on:   /  /  
 


Sprinklers and Smoke Detectors

This facility is: FULLY SPRINKLERED
 
Number of comprehensive care resident rooms: 49
Number of comprehensive care resident rooms with battery 
                    operated smoke detectors: 0
Number of comprehensive care resident rooms 
             with hard wired and/or wireless smoke detectors: 49
 
  If hard wired and/or wireless smoke detectors are provided in resident's room, do they:
    (A) Provide a visual and audible signal at the nurses'stations that attend each room? - Yes
    (B) Transmit to a central station service - Yes
    (C) Connect to the health facility's fire alarm system - Yes
 
Person completing form - JACK L MUELLER
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. EXECUTIVE DIRECTOR
Date form completed - 04/07/2025
 


Nurse Aide Training

NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved:  
Nurse aide training and competency evaluation program (NATCEP) expires:  
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 11/05/2010
 
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites: 
     MICHIANA HEALTHCARE TRAINING INC
         Approved: 03/02/2012
         Terminated: N/A
     LEGACY MEDICAL ACADEMY
         Approved: 04/17/2019
         Terminated: N/A
     EXCEL CNA AND QMA TRAINING CENTER
         Approved: 09/27/2020
         Terminated: N/A
     HOOSIER HEALTHCARE TRAINING CENTER, LLC
         Approved: 04/21/2021
         Terminated: N/A
     GATEWAY LEARNING CENTER
         Approved: 05/28/2024
         Terminated: N/A
 


Complaints

NUMBER OF SUBSTANTIATED COMPLAINTS: 
 
  Current year:  0
  Previous year:  0
  2 years previous:  0

 


Facility Report Card



 


 
03/01/2020 Current QTR
12/01/2019 Previous QTR
09/01/2019 Previous QTR
06/01/2019 Previous QTR


Report Card Score
452
440
440
440


Rank of Score
7
10
10
10


Average Score
302
296
295
296


 
*Facility report card scores have not been updated since March 1, 2020 due to changes in the survey process during the ongoing COVID-19 pandemic. 
The facility report card score is calculated four times per calendar year 
for the two most recent nursing home health surveys.  The facility report card score 
also includes all complaint surveys, life safety code surveys, emergency preparedness surveys, 
and any follow-up surveys that occur within the two most recent nursing home health surveys. 
The facility report card score ranges from 500 to 0, with 500 being the best score possible. 
 
View the Scope and Severity grid
 
View the scoring methodology
 



Overview of Survey findings




 
 The Most Recent Set
 2ND Most Recent Set
 3RD Most Recent Set

Immediate Jeopardy
No
No
No


 Substandard Quality of Care 
No
No
No


Administrator Change
No
No
Yes


Owner Change
No
No
No


Number of Substantiated Complaints With Deficiencies
0
0
0


Deficiency Free Standard Health Survey
Yes
No
No


 
    The term 'Recent Set' referenced above relates to the referenced annual survey,
    and any other surveys performed between it and the previous annual survey.
 

 


Enforcement Actions

 
Federal Certification Actions Imposed
 
Date terminated from Medicare/Medicaid: N/A
 


Survey History


    The survey report is not posted until the report has been provided to the facility and their plan of correction submitted and approved.
    The survey report therefore will likely not be posted until four to six weeks after the exit date.
        
    In the grid below click on an event ID that is underlined to see the survey report for that event.


 
Event ID
Survey Type
Exit Date

279E22
Recertification, Follow Up, Life Safety Code
05/09/2025


279E21
Recertification, Life Safety Code
04/16/2025


279E11
Recertification, State Licensure
03/13/2025


3YGN11
Complaint
09/27/2024


1N3O12
Complaint, Follow Up
07/11/2024


1N3O11
Complaint
06/26/2024


3YTZ22
Recertification, Follow Up, Life Safety Code
06/14/2024


3YTZ12
Recertification, Follow Up, State Licensure
06/04/2024


3YTZ21
Recertification, Life Safety Code
04/18/2024


3YTZ11
Recertification, State Licensure
03/25/2024


DW8H11
Complaint
09/20/2023


KAH222
Follow Up, Life Safety Code, Recertification
05/15/2023


KAH212
Recertification, Follow Up, State Licensure
04/27/2023


KAH221
Recertification, Life Safety Code
03/24/2023


KAH211
Recertification, State Licensure
02/27/2023


SS1E22
Follow Up, Life Safety Code, Other
12/16/2022


SS1E21
Life Safety Code, Other
10/21/2022


 
 


Links and Resources

 
CMS nursing home compare page 
 
    In addition to the information provided on this 
    web site, the Centers for Medicare & Medicaid Services (CMS) has a web site 
    which contains information on every Medicare and Medicaid certified nursing 
    home in the country. The CMS nursing home survey results contain summary information 
    about a facility's noncompliance of regulations regarding the care of residents 
    found in the nursing homes. You can locate nursing homes in your area and find 
    information about compliance with federal regulations.
 
Resources and links to other organizations
 
Choosing a Nursing Home
 
Overview of the Survey Process
 
State Wide Grouping of all Scores
   
Overview of current comprehensive facility scores
   
Spreadsheet of current comprehensive facility names and scores
   
Legal Disclaimer for Long Term Care Reports.