Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Healthwin Health & Rehabilitation during CMS and state inspections, most recent first.
Food was not served at a palatable temperature on the West unit. During an observation of supper trays from a covered food cart, pureed grilled cheese measured 125 degrees Fahrenheit and mashed potatoes with gravy measured 128 degrees Fahrenheit. The Dietary Director stated food should have been 135 degrees Fahrenheit at the point of service, and the facility policy required potentially hazardous food to be maintained below 41 degrees or above 135 degrees Fahrenheit.
Unsanitary kitchen and pantry conditions were observed when food items were found unsealed in the freezer, clean equipment had visible soil, storage fans and shelves were dirty or rusted, and ceilings, vents, and screens had dust, grime, and peeling paint. In nutrition pantries, surveyors found a refrigerator at 46 degrees, missing or broken thermometers, employee food stored in a pantry refrigerator, and dirty or damaged coffee machine and cabinet surfaces; the DD acknowledged these conditions should have been clean, repaired, or properly monitored.
Pest Control Program Not Ensured in Kitchen: Multiple dead bugs were observed in a light fixture above the 3-compartment sink used for washing food prep utensils. The DD stated bugs were a problem and had been reported to maintenance, but the issue had not yet been addressed. A review of maintenance requests showed only peeling paint on kitchen ceiling tiles, and no pest control policy was provided before survey exit.
A resident with multiple chronic conditions and moderate cognitive impairment was receiving antidepressant medications, including escitalopram and bupropion. The record did not show a signed psychotropic consent form dated before the medications were started, and the Interim DON could not locate consent for either medication prior to initiation.
A resident with Parkinson’s disease and dementia was identified as a fall risk and had a documented fall, but the fall care plan and interventions were not initiated until after the fall. The resident was moderately cognitively impaired, required assistance with toileting, bathing, and transfers, and reported having fallen several times. The DON stated the care plan should have been updated for the fall, and facility policy required the IDT to review and update care plans when there is a significant change in condition.
Failure to Document Assessment After a Resident Fall: A resident with dementia and Parkinson’s disease, moderate cognitive deficits, and identified fall risk had a fall followed by ER transfer, but the record lacked documentation of how the fall occurred or an assessment after the fall. The DON confirmed the assessment was not in the chart, and the facility policy required documentation of events, incidents, or accidents involving the resident.
Failure to maintain heel pressure relief for a resident with a pressure ulcer. A resident with COPD, protein calorie deficit, cognitive impairment, ROM deficits, and incontinence had heel protectors ordered and a care plan for a right heel deep tissue injury, but the care plan lacked specific heel prevention interventions initially. During wound care observation, the resident was in bed without heel protectors and both heels were resting directly on the mattress; the Wound Nurse stated staff were not applying the devices consistently and the resident sometimes kicked them off.
An LPN failed to provide G-tube site care as ordered for a resident who was nonverbal, had significant cognitive impairment, and received most of his nutrition through tube feeding. During observation, the LPN cleaned the insertion site with sterile water only instead of soap and water, and the site was reddened. The resident’s physician order and care plan directed daily and as-needed site care per order.
Delayed Urine Laboratory Testing and Improper Specimen Handling: A resident with DM, PVD, HTN, acidosis, bilateral BKA, and immunodeficiency had repeat urine culture orders after finishing IV antibiotics for a prior UTI, but the urine specimen was not received by the lab and later was found to be mislabeled with the date. Nursing notes showed multiple recollections of the urine sample, and the DON confirmed there were no UA results because the specimen had not been properly processed.
Failure to Follow Infection Control Practices During Urinal Emptying: A CNA was observed carrying a half full urinal from a resident’s room down the hallway to a unit bathroom, emptying it, and not washing her hands afterward. The CNA stated she had not washed her hands and could not recall when she last received PPE training. An RN confirmed staff must wear gloves when emptying a urinal, and the facility’s PPE policy required hand hygiene before donning gloves.
A resident with paraplegia, type 2 diabetes, osteomyelitis, pressure ulcers, and a colostomy did not have a comprehensive care plan addressing hypoglycemia, wound vac care, or ostomy care, despite physician orders and facility policy requiring such plans. The care plan lacked measurable goals and interventions for these critical areas.
A resident with diabetes and multiple wounds did not have a physician order in place for hypoglycemic care while receiving insulin, and documentation for wound and ostomy care was missing on several occasions. The DON confirmed the lack of required orders and incomplete documentation, contrary to facility policy.
The facility failed to provide sufficient nursing staff, resulting in untimely responses to call lights, missed showers, and delayed medications. Residents and families reported dissatisfaction, and CNAs described increased workloads and incomplete care tasks. The facility's staffing levels fell below the required 3.42 PPD on several occasions, leading to negative resident experiences, including accidents and unmet care needs.
The facility failed to ensure timely availability and administration of medications for several residents, leading to missed doses of critical medications such as antibiotics and insulin. The issues were exacerbated by a recent pharmacy switch, lack of communication, and inadequate procedures for obtaining medications from a backup pharmacy.
The facility failed to provide scheduled showers or bed baths to several residents, including one who had not received a shower for over two weeks due to staffing shortages. Another resident received only one bath or shower per week instead of the scheduled two, and a third resident was observed with greasy hair, indicating missed bathing. Documentation confirmed gaps in bathing records, and interviews with CNAs revealed that staffing issues prevented consistent adherence to bathing schedules.
The facility failed to follow physician orders for a resident requiring Tubi-grips for leg swelling and did not assess or document a skin condition for another resident. Despite orders, the first resident was observed without Tubi-grips, leading to swelling. The second resident had undated dressings on a skin tear, with no documentation or assessment as required by facility policy.
A resident reported verbal abuse by a nurse who allegedly yelled at her for not attending meal service. Initially dismissed by the DON as a cultural difference, the incident was later investigated and reported to the IDOH. The resident, with a history of depression and PTSD, was left tearful and distressed.
A resident with cognitive and physical impairments was observed multiple times with a fastened seat belt in a wheelchair, unable to remove it independently. Despite a physician's order and facility policy requiring the resident to be able to remove the seat belt, staff used it to prevent the resident from sliding or rising unassisted. The facility failed to conduct ongoing evaluations of the seat belt as a restraint, contrary to their policy.
A resident reported an incident of verbal abuse by a nurse to the DON, who did not report it to the state health department in a timely manner, believing it was a cultural misunderstanding. The resident, who was cognitively intact and had a history of PTSD and depression, expressed distress over the incident. The facility's policy requires immediate review and reporting of abuse allegations, which was not followed in this case.
A facility failed to develop a comprehensive care plan for a resident with osteomyelitis and an indwelling catheter. Despite physician orders and a history indicating the need for specific care, the resident's record lacked plans addressing these conditions. The DON acknowledged the oversight, which was contrary to the facility's policy requiring updates to care plans with significant changes in condition.
The facility failed to provide activities that met the interests and well-being of two residents with severe cognitive impairments. One resident, with Alzheimer's and other conditions, was observed in her room without engagement in activities despite preferences for music and religious activities. Another resident, with dementia and other health issues, was similarly observed without engagement, despite preferences for outdoor activities and music. Documentation of group activities or one-on-one visits was lacking for both residents during specified periods.
The facility failed to provide clinical justification for the continued use of an indwelling catheter for a resident with multiple health conditions. Despite a physician's order for a Foley catheter, there was no documentation supporting its necessity. A Nurse Practitioner mentioned the catheter was for wound healing, but no current open wounds were documented. The DON was unaware of the catheter's purpose, and the facility's policy lacked assessment or documentation requirements for continued catheter use.
A facility failed to follow physician's orders for a resident's enteral feeding, resulting in incomplete administration of Osmolite 1.5 over several days. The resident, who was severely cognitively impaired and dependent on the feeding tube for over 51% of caloric intake, did not receive the full prescribed volume. The facility also failed to notify the physician about the incomplete feedings, as required by their policy.
A resident with a fractured arm did not receive necessary assistance with her CPAP equipment, leading to improper use and maintenance. The CPAP mask and tubing were repeatedly observed uncovered and not sanitized, and the resident reported not wearing the CPAP due to lack of help. Despite having a care plan and physician's orders, the facility failed to ensure compliance with respiratory care standards.
The facility failed to follow infection control standards for residents using oxygen or CPAP machines. A resident's CPAP mask was improperly stored in a non-functional SoClean machine. Another resident's oxygen tubing and humidification bottle were not changed as ordered, and a third resident's oxygen equipment was undated and improperly stored. The facility's policy lacked guidance on storing unused oxygen equipment.
A resident with multiple medical conditions and high fall risk was improperly transferred using a Hoyer Lift, resulting in her slipping from the sling. Despite being caught by a CNA, the resident was lowered to the floor. Initial assessments showed no injury, but later evaluations revealed fractures. The facility's policies on lift use and fall management were reviewed, but the investigation did not clarify how the resident slipped from the sling.
Food Served Below Required Temperature
Penalty
Summary
Food was not served at a palatable temperature for 1 of 4 nursing units, the West unit. During an observation and temperature check of supper trays from a covered food cart on the [NAME] 2 unit, pureed grilled cheese measured 125 degrees Fahrenheit and mashed potatoes with gravy measured 128 degrees Fahrenheit. During interview, the Dietary Director stated the food should have been 135 degrees Fahrenheit at the point of service. A policy titled, Food Preparation and Service, provided by the DON, indicated potentially hazardous food must be maintained below 41 degrees or above 135 degrees Fahrenheit.
Unsanitary kitchen and pantry conditions
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner in 1 of 1 kitchens. During an initial observation of the kitchen with the Dietary Director (DD), surveyors noted a bag of frozen chicken strips and french fries in the reach-in freezer that was opened and unsealed, a baking tray stored as clean with a brown substance on the bottom, a fan in the dry storage area with visible dust and grime, a silverware caddy with a brown sticky substance on it, and white metal shelves above the food prep area with chipped paint and rust. During interview, the DD stated the chicken and french fries should have been sealed, the tray should have been clean, the fan should have been clean, the silverware caddy should have been clean, and the metal shelves should have been painted. On a later observation, the ceiling over the prep area in the kitchen was dirty and the paint was peeling, and in the Alcove the ceiling vent, surrounding ceiling and wall, and two ceiling screens were dusty and dirty with heavy accumulation. The DD stated these areas should have been clean and said maintenance had been notified but had not taken care of the issues yet. Additional observations of nutrition pantries found a refrigerator at 46 degrees with a rusty freezer shelf, another refrigerator and freezer without thermometers and with an employee's food stored inside, a broken refrigerator thermometer, a coffee machine tray with a brown and white crust, and a cabinet drawer and door with missing finish and buckling. The DD stated refrigerators should have working thermometers and temperatures no higher than 41 degrees, employee food should not have been stored in the pantry refrigerator, and the tray, drawer, and door should have been clean or repaired.
Pest Control Program Not Ensured in Kitchen
Penalty
Summary
The facility failed to ensure bugs were controlled in 1 of 1 kitchen. During an observation of the kitchen on 4/17/2026 at 9:53 A.M., multiple dead bugs were noted in a light fixture above the 3-compartment sink used to wash food preparation utensils. During an interview at that time, the DD stated bugs were a problem and had been reported to the maintenance department, but the issue had not yet been addressed. On 4/20/2026 at 10:25 A.M., a list of maintenance requests for the past 6 months was provided, and the only issue listed was peeling paint on kitchen ceiling tiles. On 4/22/2026 at 2:00 P.M., a policy regarding pest control was requested, but one was not provided before survey exit.
Failure to Obtain Timely Psychotropic Medication Consent
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medication administration for Resident 3. The resident’s record showed diagnoses including gastrostomy status, difficulty walking, dysphagia, chronic kidney disease, hypertension, history of prostate cancer, obstructive sleep apnea, irritable bowel syndrome, tremor, paroxysmal atrial fibrillation, and polyneuropathy. A quarterly MDS dated 2/24/2026 indicated the resident was moderately cognitively impaired and was receiving an anticoagulant and an antidepressant. Physician orders showed Escitalopram Oxalate 20 mg daily, initiated 10/14/2025, and Bupropion Hydrochloride 100 mg three times daily, initiated 10/22/2025. The care plan, initiated 9/12/2025, indicated the resident received an antidepressant medication. A psychotropic medication consent form was dated and signed 12/22/2025 for these medications, but the clinical record did not evidence a signed psychotropic consent form dated prior to the resident beginning the psychotropic medications. The Interim DON stated he was unable to locate a signed psychotropic consent for either medication prior to initiation, and the Executive Director provided the facility policy titled, Antipsychotic Medication Use.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to update a resident’s care plan after a fall for 1 of 3 residents reviewed for falls. Resident 16 had diagnoses including Parkinson’s disease and dementia, was moderately cognitively impaired on the admission MDS dated 4/6/2026, and required substantial assistance with toileting and bathing and partial to moderate assistance with transfers. The admission Fall Risk Assessment completed on 3/30/2026 identified the resident as a fall risk and documented a fall on 4/4/2026, but the care plan for falls and fall-prevention interventions was not initiated until 4/13/2026, after the fall. During interview, the resident stated he had fallen several times, and a fall mat was observed next to the bed. The DON stated the care plan should have been updated for the fall, and the facility policy indicated the interdisciplinary team is responsible for reviewing and updating care plans when there is a significant change in condition.
Failure to Document Assessment After a Resident Fall
Penalty
Summary
The facility failed to assess a resident after a fall for 1 of 3 residents reviewed for falls. Resident 16 stated during interview that he had fallen several times and had gone to the emergency room twice because of the falls. During observation, a fall mat was noted on the floor next to the resident’s bed. The resident’s diagnoses included dementia and Parkinson’s disease, and the admission MDS indicated a moderate cognitive deficit, maximum assistance needed for bathing and toileting, and moderate assistance needed for bed mobility and transfers. The resident was also identified as being at risk for falls on the admission fall risk assessment. Record review showed that on 4/4/2026 the resident was transferred to the emergency room for chest pain and follow-up from a fall, but no other documentation was found describing how the fall occurred or documenting an assessment after the fall. A care plan problem initiated on 4/13/2026 identified the resident as at risk for falls and included interventions such as keeping the bed in the lowest position, using footwear to prevent slipping, and keeping the call light and personal items in reach. During interview, the DON stated there was not an assessment related to the fall in the record and that an assessment should have been documented. The facility policy titled, Charting and Documentation, stated that events, incidents, or accidents involving the resident should be documented in the medical record.
Failure to Maintain Heel Pressure Relief
Penalty
Summary
The facility failed to ensure preventative measures were implemented for a resident with a pressure ulcer. Resident 10 had diagnoses including chronic obstructive pulmonary disease and a protein calorie deficit, and the Quarterly MDS dated 2/19/2026 indicated moderate cognitive deficit, range of motion deficits in both lower extremities, maximal assistance needed for bed mobility and transfers, frequent bladder incontinence, and total bowel incontinence, with no pressure ulcers at that time. The care plan for pressure ulcer risk, initiated on 9/4/2025, included interventions such as adequate hydration and nutrition, keeping skin clean and dry, a pressure reducing mattress, skin assessments as indicated, and assessment for risk of skin breakdown, but it did not include specific preventative interventions for the resident’s heels. Physician orders included heel protectors daily, with removal allowed for wound and ADL care and then re-application, and a later order for treatment of a right lateral heel wound. A care plan problem initiated on 4/2/2026 identified a deep tissue injury to the right heel and included heel protectors while in bed and keeping heels up while in bed. During observation of wound care on 4/21/2026, the resident was found in bed without heel protectors and with both heels resting directly on the mattress. The Wound Nurse stated on interview that staff were not applying the heel protectors consistently and that the resident sometimes kicked them off, and that the resident should have had heels off the mattress with heel protectors in place.
G-tube site care not provided as ordered
Penalty
Summary
The facility failed to provide gastrostomy tube (G-tube) care as ordered by the physician for one resident observed receiving G-tube care. During an observation, an LPN removed the dressing around the resident’s G-tube, cleaned the skin with sterile water only, and applied a clean dressing. The skin around the G-tube insertion site was noted to be reddened, and the LPN stated she had not used soap and was not sure whether soap was supposed to be used during the dressing change. The resident had diagnoses including dysphagia, aphasia, hemiplegia, and hemiparesis of the left side. The resident’s MDS indicated he was nonverbal, rarely or never understood by others and rarely or never understood others, had significant cognitive impairment, was dependent on staff for all transfers, personal hygiene, and bathing, and received 51% or more of daily caloric requirements from G-tube feeding. A current physician order directed that the G-tube site be cleaned with soap and water and a new drain sponge applied daily and as needed, and the care plan directed tube insertion site care per physician order.
Delayed Urine Laboratory Testing and Improper Specimen Handling
Penalty
Summary
The facility failed to ensure laboratory services were obtained timely for one resident whose urine testing was being followed after completion of IV antibiotics for a prior urinary tract infection. The resident had diagnoses including diabetes mellitus, peripheral vascular disease, hypertension, acidosis, bilateral below-knee amputations, and immunodeficiency due to conditions classified elsewhere. The resident reported having a PICC line in place and stated that a urine sample had been sent to the lab to determine whether the PICC line could be removed, but no one had followed up on the urine sample results. The quarterly MDS dated 1/16/2026 did not indicate the resident had a PICC line. Physician orders included repeat urine cultures on 4/3/2026 and 4/7/2026, and a stat urine and culture order on 4/17/2026. Nursing documentation showed the resident completed antibiotics on 4/4/2026, that a urine sample had been obtained but not received by the laboratory on 4/11/2026, and that additional urine samples were collected on 4/17/2026 and again on 4/21/2026 after the laboratory indicated the specimen needed to be recollected. The DON stated the facility called the laboratory for UA results and was told the urine had never been received, and later stated the laboratory reported no UA results because the urine sample was not labeled correctly with the date. The facility policy required specimens sent for laboratory testing to be labeled with the date the specimen was obtained and to contact the physician/practitioner if the test was not obtained.
Failure to Follow Infection Control Practices During Urinal Emptying
Penalty
Summary
The facility failed to ensure infection control practices were followed when emptying a urinal for one resident observed for urinal care. During an observation on 4/21/2026 at 2:30 P.M., CNA 15 was seen exiting Resident 40's room carrying a half full urinal down the hallway to the unit bathroom. She had wet wipes in her hand grasping the urinal handle, emptied the urinal, and was not noted to wash her hands afterward. During an interview on 4/21/2026 at 2:32 P.M., CNA 15 stated that carrying the urinal in that manner was proper technique, that gloves were not to be worn in the hallway, and that she had not washed her hands after emptying the urinal. She also stated she had received training on PPE but could not recall when. On 4/22/2026 at 12:11 P.M., RN 14 stated staff were not supposed to go outside resident rooms with gloves on, but were allowed to do so when emptying resident urinals because many resident rooms did not have bathrooms, and she confirmed staff must wear gloves when emptying a urinal. A policy titled Personal Protective Equipment-Donning and Doffing dated 1/5/2025 stated staff, residents, and visitors would be provided education on proper use and donning and doffing PPE, and that hand hygiene was to be performed before donning gloves.
Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical needs. The resident had diagnoses including paraplegia, type 2 diabetes, osteomyelitis of the left femur requiring surgical intervention and wound vac placement, colostomy status, and multiple pressure ulcers. The clinical record review showed that the resident required extensive assistance with activities of daily living and was receiving insulin injections for diabetes management. Physician orders included specific instructions for insulin administration, wound vac care, and ostomy care. Despite these documented needs and orders, the resident's care plan did not include goals or interventions for managing low blood sugar (hypoglycemia), wound vac care for pressure ulcers, or ostomy care. The facility's policy required a baseline care plan to be developed within 48 hours of admission to address immediate care needs, but this was not completed for the resident in question. The deficiency was identified through interviews and record reviews, confirming the lack of a comprehensive, measurable care plan for the resident's conditions.
Failure to Ensure Physician Orders and Documentation for Diabetic and Wound Care
Penalty
Summary
The facility failed to ensure that physician orders were in place for the treatment of low blood glucose and did not complete documentation for wound care treatment according to physician orders for one resident. Specifically, a resident with multiple diagnoses including paraplegia, type 2 diabetes, osteomyelitis, and pressure ulcers was receiving insulin but did not have a physician's order for hypoglycemic care. Additionally, there were missing documentation entries for the administration of Santyl ointment for wound care on several dates, as well as missing documentation for ostomy care on specific shifts. Interviews with the DON confirmed the absence of a physician's order for hypoglycemic care and acknowledged missing documentation related to the resident's wound and ostomy care. Facility policies required documentation of wound assessments at the time of each treatment and the use of routine standing orders for diabetes management unless otherwise specified by a physician, but these were not followed in this case.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by multiple complaints from residents and their families about untimely responses to call lights, missed showers, and delayed or missed medications. During a resident and surveyor group meeting, all 22 residents present expressed dissatisfaction with the timeliness of care, including not receiving at least two showers a week and not receiving medications on time. Family members also voiced concerns about inadequate staffing, particularly at night, during a meeting with corporate representatives and the Director of Nursing (DON). Interviews with Certified Nursing Assistants (CNAs) revealed that staffing levels had decreased, leading to increased workloads and an inability to complete essential care tasks. CNAs reported being assigned to care for up to 14 residents, which resulted in rushed care, missed showers, and incomplete charting. The DON acknowledged that the facility was adjusting to new corporate staffing patterns and had not received complaints from families or residents until media attention highlighted the issue. The facility's assessment indicated a required staffing level of 3.42 hours of direct nursing care per resident per day (PPD), but actual staffing levels on several dates fell below this requirement. Residents reported negative experiences due to insufficient staffing, including waiting long periods for assistance, which led to accidents and feelings of embarrassment. One resident described having to wait to use the toilet, resulting in back pain and an accident, while another resident was unable to get out of bed or receive basic care over a weekend. The facility's policy on nursing staffing did not specify requirements or adjustments based on resident acuity, contributing to the deficiency in meeting residents' needs.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered as prescribed for several residents. Resident 86 did not receive the antibiotic Vancomycin for a Clostridium difficile infection until two days after it was ordered, despite the positive test result and the physician's order. The delay was due to the pharmacy not delivering the medication on time, and there was no documentation that the physician was notified of the delay. Additionally, the facility's emergency drug kit did not contain the necessary medication, and there was a lack of communication with the pharmacy regarding the urgency of the situation. Resident M missed two doses of the antibiotic ertapeneum for sacral osteomyelitis, and there was no documentation of refusal or notification to the physician about the missed doses. Similarly, Resident L did not receive doses of Tamiflu for an influenza infection, and Resident N missed doses of cephalexin for a urinary tract infection, with no documentation of physician notification. Resident O also missed multiple doses of various medications, including insulin and antibiotics, without documentation of refusal or physician notification. The facility experienced ongoing issues with medication availability due to a recent switch in pharmacies, which affected the timely delivery of medications. The nursing staff and supervisors were not adequately informed about the procedures for obtaining medications from a backup pharmacy, leading to further delays. Additionally, there were instances where medications were not administered as ordered, such as Resident 47 not receiving Baqsimi for low blood sugar and Resident 71 not receiving Midodrine for low blood pressure, despite clear physician orders and care plans indicating the need for these interventions.
Failure to Provide Scheduled Showers and Baths
Penalty
Summary
The facility failed to ensure that dependent residents received showers or complete bed baths as scheduled, affecting five out of eight residents reviewed. Resident B, who was scheduled to receive three showers a week, had not received a shower for over two weeks due to staffing shortages. Despite being alert and oriented, Resident B was upset about not receiving showers, and her family member's attempts to contact the Administrator went unanswered. The Treatment Administration Record (TAR) confirmed multiple missed showers, and there was no documentation of any refusals by Resident B. Resident M also did not receive the scheduled two bed baths or showers per week, often receiving only one. Her care plan indicated she was dependent on staff for bathing, and the TAR showed missed showers on specific dates. The Director of Nursing confirmed that Resident M should have received either a shower or a complete bed bath twice a week. Similarly, Resident 55 was observed with greasy hair, and her medical record lacked documentation of bathing from mid-January to late January. Interviews with CNAs revealed that residents were supposed to be bathed or showered three times per week, but staffing issues prevented this from happening consistently. Resident D's family reported that she had not been receiving her showers regularly, and documentation confirmed gaps in bathing records. CNAs indicated that the absence of a shower aide affected their ability to provide scheduled showers. Resident E's family noted that she had not received her scheduled showers, leading to a yeast infection in her groin area. The facility's policy required residents to receive proper daily personal attention and care, including bathing at least twice weekly, but this was not adhered to, as evidenced by the lack of documentation and observations of residents' unkempt appearances.
Failure to Follow Physician Orders and Assess Skin Conditions
Penalty
Summary
The facility failed to adhere to physician orders and provide appropriate care for two residents, leading to deficiencies in their treatment. Resident J, who had diagnoses including post-polio syndrome and Parkinson's disease, was ordered to wear Tubi-grips on her legs and feet at all times to manage swelling. Despite this, observations over several days showed that Resident J was not wearing the Tubi-grips, and her right lower leg and foot were swollen. The resident was dependent on staff for dressing and had not refused the Tubi-grips, yet the facility did not ensure she wore them as prescribed. The Director of Nursing confirmed that Resident J should have been wearing the Tubi-grips, and there was no policy provided for following physician orders. For Resident 67, the facility failed to assess and document a skin condition properly. Observations revealed undated dressings on the resident's right arm, with bloody drainage and a skin tear underneath. The RN was unaware of the condition and confirmed that the dressings should have been dated and documented. Despite a physician's order for weekly skin assessments, records indicated no new skin issues, and there was no documentation of the impaired skin integrity. The facility's policy required weekly skin observations and reporting of new skin issues to the physician, which was not followed in this case.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a nurse who allegedly yelled at a resident. The resident, who was cognitively intact and had a history of depression, anxiety, and post-traumatic stress disorder, reported feeling unwell and chose not to attend meal service. During this time, the nurse reportedly raised her voice, demanding the resident to get out of bed and go to the dining room, which left the resident tearful and distressed. The resident reported the incident to the Director of Nursing (DON) the following day, but the DON initially dismissed it as a cultural difference and did not report it to the Indiana Department of Health (IDOH) as abuse. Upon further discussion with a surveyor, the DON began investigating the resident's claims and subsequently reported the incident to the IDOH. The investigation revealed that the nurse denied raising her voice, and the resident later indicated to the DON that she no longer felt the nurse had yelled at her. The facility's policy on abuse, which includes verbal and mental abuse, defines abuse as the willful infliction of intimidation. However, the initial failure to recognize and report the incident as potential abuse highlights a deficiency in the facility's response to allegations of abuse.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed in the case of a resident who was unable to remove a seat belt while seated in a wheelchair. The resident, who was diagnosed with conditions including osteoarthritis, dementia, and metabolic encephalopathy, was observed multiple times with a fastened seat belt across his lap. Despite a physician's order requiring staff to command the resident to remove the seat belt and notify the therapy department of failed attempts, the resident was unable to release the seat belt on several occasions. Interviews with various CNAs and an RN revealed that the seat belt was used to prevent the resident from sliding out of the wheelchair or getting up unassisted, due to his cognitive impairments and physical limitations. However, the staff acknowledged that the resident was unable to unbuckle the seat belt independently, contradicting the facility's policy that restraints should only be used if the resident can remove them upon command. The Director of Therapy confirmed that the seat belt was intended as a positional device and should not be used if the resident could not remove it. The facility's policy on physical restraints stated that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully. The policy also defined a restraint based on the resident's functional status, indicating that if a resident cannot remove a device, it is considered a restraint. Despite this, the facility did not conduct ongoing evaluations of the seat belt as a restraint, as the DON believed it was not a restraint since the resident could remove it when asked. This oversight led to the continued use of the seat belt without proper re-evaluation, contrary to the facility's policy.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report a resident's allegation of verbal abuse in a timely manner to the Indiana Department of Health. A resident, who was cognitively intact and had a history of post-traumatic stress disorder and depression, reported to the Director of Nursing (DON) that an agency nurse had yelled at her during an evening shift. The incident reportedly occurred two to three weeks prior to the resident's interview with the surveyor. The resident expressed distress over the incident, indicating that the nurse had raised her voice when the resident did not want to attend meal service due to feeling unwell. The resident reported the incident to the DON the day after it occurred, but the DON did not report it to the state health department, believing it was a cultural misunderstanding rather than abuse. The DON recalled the incident but did not take immediate action to report it as an allegation of abuse. It was only after a discussion with the surveyor that the DON began investigating the claims and reported the allegation to the Indiana Department of Health. The facility's policy on abuse requires immediate review and investigation of all allegations, with reporting to occur within 24 hours if the events do not result in serious bodily injury. The delay in reporting the incident to the appropriate authorities constituted a failure to adhere to this policy, as the allegation was reported weeks after the resident initially brought it to the DON's attention.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented for a resident diagnosed with osteomyelitis and using an indwelling catheter. The resident, identified as Resident Q, had multiple diagnoses including osteomyelitis of the right foot/ankle, diabetes mellitus type 2, anxiety, depression, hypertension, and chronic kidney disease stage 3. Despite a physician's order for ceftazidime IV for osteomyelitis and a history and physical evaluation indicating chronic osteomyelitis, the resident's record lacked a care plan addressing this condition. Additionally, there was a physician's order for a Foley catheter, but the resident's record did not include a care plan for its use. During an interview, the Director of Nursing (DON) acknowledged that care plans should be updated with new orders identified during the morning clinical meeting and confirmed that the care plan should be current. However, she was unaware of why Resident Q did not have a care plan for osteomyelitis or the Foley catheter. The facility's policy on comprehensive person-centered care planning requires the interdisciplinary team to review and update care plans with significant changes in resident condition, changes in needs, and upon return from a hospital stay. This policy was not adhered to in the case of Resident Q, leading to the deficiency.
Failure to Provide Adequate Activities for Residents
Penalty
Summary
The facility failed to provide activities that met the interests and well-being of two residents, as observed during a survey. Resident 55, who has severe cognitive impairment due to Alzheimer's disease and other conditions, was observed multiple times in her room either in a Broda chair or lying in bed, with the television on but not actively engaged in any activities. Despite having preferences for activities such as visiting with pets, listening to music, and participating in religious activities, there was no documentation of her attending group activities or receiving one-on-one visits from 2/3/2025 to 2/10/2025. The care plan for Resident 55 indicated she was unable to initiate activities and required one-on-one visits twice weekly, which were not documented during the specified period. Similarly, Resident 83, who also has severe cognitive impairment and other health issues, was observed in her room in a Broda chair or lying in bed with the television or radio on but not engaged in any activities. Her care plan indicated a goal of participating in one to two group or individual activities weekly, with preferences for going outside, listening to music, and being around pets. However, there was no documentation of her attending any group activities or receiving one-on-one visits from 2/2/2025 to 2/10/2025. The Activities Director mentioned having completed one-on-one visits with both residents, but these visits were not documented in the electronic medical record as required.
Lack of Justification for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure there were clinical indications to support the continued use of an indwelling catheter for a resident reviewed for catheters. The resident, who had diagnoses including osteomyelitis, diabetes mellitus type 2, anxiety, depression, hypertension, and chronic kidney disease stage 3, had a physician's order for a Foley catheter. However, there was no documentation justifying the need for the catheter. A Nurse Practitioner noted the catheter was in place for wound healing, but there was no evidence of any current open wounds that could be contaminated by urine. During an interview, the Director of Nursing was unaware of the reason for the catheter's use. Additionally, the facility's urinary catheter care policy did not include any assessment or documentation requirements to support the continued use of an indwelling catheter.
Failure to Administer Prescribed Enteral Feedings
Penalty
Summary
The facility failed to adhere to the physician's orders regarding enteral feedings for a resident with a gastronomy tube (G-tube). Observations over three consecutive days revealed that the resident's enteral feeding bottles were not fully administered as per the prescribed amount. Specifically, bottles of Osmolite 1.5 were found disconnected and hanging on an IV pole with significant amounts of formula remaining, indicating that the resident did not receive the full prescribed volume of 1200 mLs per day. The bottles were also not properly dated, and there was no documentation that the physician was notified about the incomplete feedings. The resident in question, who was severely cognitively impaired, relied on the feeding tube for more than 51% of their caloric intake. Despite the clear physician's order to administer 75 mLs per hour for sixteen hours, the facility's records lacked evidence of communication with the physician regarding the shortfall in feeding. The facility's policy on enteral feedings required documentation of the administration details, which was not followed, contributing to the deficiency.
Failure to Assist Resident with CPAP Use and Maintenance
Penalty
Summary
The facility failed to provide necessary assistance to a resident with a fractured arm in applying and maintaining her CPAP equipment. Observations revealed that the CPAP mask and tubing were left uncovered on an opened SoClean machine, and the resident reported that she did not receive help to wear the CPAP due to her broken arm. Despite having a physician's order for CPAP use at bedtime and a care plan in place, the resident indicated she was unable to use the CPAP because no assistance was provided, and the equipment was not cleaned as required. The resident, who has chronic obstructive pulmonary disease and obstructive sleep apnea, was observed multiple times without her CPAP equipment being properly stored or sanitized. The Treatment Administration Record indicated inconsistencies in the documentation of CPAP use and cleaning. Interviews with staff confirmed that the CPAP was not always in the sanitizer when not in use, contrary to the facility's policy. The facility's policy on CPAP/BIPAP guidance was provided, but it was undated and did not ensure compliance with professional standards of practice.
Infection Control Deficiencies in Oxygen and CPAP Equipment Management
Penalty
Summary
The facility failed to adhere to infection control standards for three residents using supplemental oxygen or CPAP machines. Resident 27's CPAP mask was observed in a SoClean machine that was not operational, lacked a lid, and contained dust. Despite a physician's order to disinfect the CPAP mask using the SoClean machine, the equipment was not maintained properly, as confirmed by the Unit Manager. Resident 27's medical conditions included Parkinson's disease, sleep apnea, anxiety, and dysphagia. Resident 95 reported that her oxygen tubing and humidification bottle had not been changed in over a month, contrary to a physician's order for weekly changes. Observations showed the tubing was unbagged and undated. The Unit Manager confirmed the equipment should have been dated and stored properly. Similarly, Resident 11's oxygen tubing and nebulizer were found undated and improperly stored. The facility's policy on oxygen administration did not specify storage procedures for unused equipment, as noted by the Director of Nursing and the Infection Prevention Nurse.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe use of a Hoyer Lift for a resident, identified as Resident D, who was at high risk for falls due to multiple medical conditions including a non-traumatic brain injury, insulin-dependent diabetes, seizure disorder, and aphasia. The resident was non-verbal and fully dependent on staff for transfers, as indicated in her care plan, which required the use of a mechanical lift with two staff members. During a transfer from a recliner to a bed, the resident slipped from the Hoyer sling, and although caught by a CNA, was lowered to the floor. The incident occurred when two CNAs were conducting the transfer. CNA 3 attached the sling to the Hoyer lift while CNA 2 operated the controls. Despite the sling being attached, the resident began to slip out of it during the transfer. CNA 3 managed to catch the resident, preventing her from hitting the floor, but the resident was still lowered to the ground. The CNAs reported that the resident did not hit her head or limbs on any objects, and the sling remained attached to the lift. However, there was uncertainty about whether the sling was properly positioned or secured, as CNA 2 assumed the sling was crossed from previous use. Following the incident, the resident was assessed and initially showed no signs of pain or injury. However, subsequent medical evaluations revealed fractures in the resident's left tibia, fibula, and left thumb, as well as bone demineralization. The facility's policies on lift use and fall management were reviewed, but the investigation did not clarify how the resident slipped from the sling if it was properly attached. The incident was self-reported by the facility after the fractures were discovered during a hospital evaluation.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 526 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellbrooke Of South Bend | 1.6 mi | ★★★★★ | 19 | 0 |
| West Woods Of Niles | 2.3 mi | ★★★★★ | 24 | 1 |
| Majestic Care Of South Bend | 2.5 mi | ★★★★★ | 56 | 0 |
| Holy Cross Village At Notre Dame Inc | 2.9 mi | ★★★★★ | 20 | 0 |
| Holy Cross Rehabilitation And Wellness | 3.4 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.