All 22 residents who attended a federal inspection meeting at Healthwin Health & Rehabilitation on February 13 complained about the same problems: delayed responses to call lights, missing their required two weekly showers, and not receiving medications on time.
The complaints came during a February inspection that found the facility failed to maintain adequate staffing levels on multiple dates, leaving some nursing assistants to care for 14 residents alone on weekends.
CNA 15 described working by himself on a nursing unit one Sunday with 14 assigned residents. Three required feeding assistance in their rooms, and by the time he finished serving breakfast trays, lunch had arrived. "The residents were so upset with him because their call lights were also not answered timely," inspectors wrote. He managed to check and change some residents but couldn't complete the four scheduled showers or finish his required documentation. "Residents that were usually continent had ended up wetting themselves because he could not assist them timely and they were very upset."
The facility's own assessment determined it needed 3.42 hours of direct nursing care per resident per day. But actual staffing fell below that level on January 20, 21, 26, February 1, 15 and 16.
CNA 6 told inspectors she was assigned 10 residents to prepare for breakfast by 8:30 AM but didn't have time for extras like nail care, hair styling or showers. She had only managed to pass ice water to four residents that morning. "Due to the lack of staffing, she had noticed there were now odors in the hallways," the report stated.
Weekend conditions deteriorated further. CNA 14 completed only one of four scheduled showers on Saturday and none on Sunday while caring for 14 residents. CNA 2 couldn't finish showers, nail care or required documentation for his 11 assigned residents.
Resident L described his weekend care as "non-existent." He went without fresh ice water despite asking for it, remained in bed in a hospital gown all weekend, and eventually had a bowel accident on the floor after trying to hold it for over an hour. "He indicated he was so embarrassed about the accident."
Resident C, who had been at the facility for five weeks, received only one shower during her entire stay and was never offered additional ones.
The staffing problems coincided with medication delivery failures that left residents without critical treatments for days. Resident 86 waited from February 12 to February 14 for an antibiotic to treat a serious C. difficile bowel infection. The medication was ordered after lab results confirmed the infection, but the pharmacy didn't deliver it for two days.
Nursing notes documented the delay: "medication not available to administer" appeared repeatedly in the resident's chart on February 13 and 14. Staff didn't notify the physician about the treatment delay or contact the pharmacy about the urgency.
Six residents experienced medication availability problems during the inspection period. Resident M missed two doses of an antibiotic for bone infection. Resident N didn't receive three scheduled doses of an antibiotic for urinary tract infection, with nursing notes indicating "medication was not available."
The facility had switched pharmacies and was experiencing delivery delays from the new provider in Indianapolis. The nursing supervisor didn't know how to contact the backup pharmacy and said even emergency orders took several hours to arrive.
Staff also failed to administer medications correctly when they were available. Resident 47, who has diabetes, had blood sugar readings of 60 or below on four occasions between December and February but never received the emergency nasal medication ordered for dangerously low blood sugar levels.
During a February 12 family meeting, relatives confronted new corporate representatives about reduced staffing and the elimination of medication aides and shower assistants. The Director of Nursing said staff weren't fired but received fewer work hours. A corporate representative claimed the facility maintained 3.5 hours of daily nursing care per resident, above the national average.
The meeting ended abruptly when family members became "emotional and loud" after being told individual concerns wouldn't be addressed.
CNA 5 described the changes: the facility previously had three nursing assistants per unit, plus a nurse, medication aide, shower aide and restorative aide for day and evening shifts. Now each unit had only two aides, with shower aides working just a couple times weekly. Night shifts had one nursing assistant covering all units.
The Director of Nursing told inspectors she hadn't received staffing concerns from families or residents "until the newscasters had came to the facility," though she acknowledged nursing staff had voiced concerns about the new corporation's staffing patterns.
CNA 6 said she was frequently asked to work extra shifts and stay late. "She indicated she was suffering from burn out."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Healthwin Health & Rehabilitation from 2025-02-19 including all violations, facility responses, and corrective action plans.
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