SOUTH BEND, IN - A February 2025 federal inspection at Healthwin Health & Rehabilitation uncovered widespread deficiencies affecting the facility's 98 residents, including staffing shortages that left some nursing units with a single aide caring for 14 residents and pharmacy failures that delayed critical antibiotic treatments for days.
Residents Report Care Delays Across Multiple Domains
During a resident group meeting on February 13, 2025, all 22 residents in attendance raised complaints about three key issues: untimely responses to call lights, failure to receive at least two showers per week, and medication administration problems. These concerns were echoed at a family meeting held the previous day, where relatives questioned facility leadership about reduced staffing levels.
According to the inspection report, the Director of Nursing acknowledged that Qualified Medication Aides and shower aides had not been terminated but were "just not given as many work hours." A corporate representative stated the facility operated at 3.5 hours of direct nursing care per resident per day, claiming this exceeded the national average. However, inspectors found the facility's own assessment indicated staffing requirements of 3.42 hours per day, and actual staffing fell below even this level on multiple dates in January and February 2025.
The situation reached a critical point on certain weekends. One certified nursing assistant reported working alone on an entire nursing unit, responsible for 14 residents. Of those 14, three required feeding assistance in their rooms. By the time breakfast service concluded, lunch trays had already arrived to the unit. The aide was unable to complete scheduled showers, finished only half of required documentation, and could not respond promptly to call lights.
The consequences of these staffing gaps extended beyond inconvenience. Residents who were typically continent experienced incontinence episodes because staff could not assist them in time. One resident stated she had to ask her husband to help her with a bedpan because no staff answered her call light. When he attempted to assist, the bedpan spilled onto the bed linens. Another resident reported remaining in bed wearing only a gown for an entire weekend because there was only one aide working. He attempted to hold a bowel movement for over an hour but was ultimately unable to wait for assistance.
Pharmacy Failures Delay Antibiotic Treatment
The inspection identified a pattern of medication delivery failures that left residents without prescribed antibiotics for extended periods. The facility had recently switched pharmacy providers, and the transition created significant gaps in medication availability.
One resident with a confirmed Clostridium difficile (C. diff) infection waited approximately two and a half days to receive the first dose of oral Vancomycin after it was ordered. C. diff is a potentially serious bacterial infection of the intestines that can cause severe diarrhea, colitis, and in serious cases, sepsis and death. Prompt antibiotic treatment is essential to control the infection and prevent complications.
Lab results confirming the C. diff diagnosis were dated February 12, 2025, and the antibiotic was ordered the same day. Progress notes documented the medication had not arrived from the pharmacy on February 13 at three separate times and again on February 14 at two times. The resident's first dose was not administered until 11:00 P.M. on February 14, 2025. The record contained no documentation that a physician had been notified of the treatment delay.
The medication availability problems affected multiple residents with serious infections:
- A resident with sacral osteomyelitis (bone infection) missed two doses of intravenous ertapenem on February 13 and 16, 2025 - A resident diagnosed with Influenza A missed both doses of Tamiflu on February 12, 2025 - A resident with a urinary tract infection did not receive three scheduled doses of cephalexin - A resident with osteomyelitis missed multiple doses of insulin, intravenous daptomycin (antibiotic), Vitamin D, and metformin - A resident with osteomyelitis and influenza waited four days for ceftazidime antibiotic delivery after it was ordered
Osteomyelitis, an infection of the bone, requires consistent antibiotic therapy to prevent the infection from spreading or becoming resistant to treatment. Interruptions in antibiotic courses can reduce effectiveness and potentially allow bacteria to develop resistance, making the infection more difficult to treat.
The Nursing Supervisor acknowledged the facility had experienced difficulties obtaining prescriptions since switching pharmacies. She explained that if a medication was unavailable, nurses were supposed to notify the supervisor, who would attempt to obtain it from an Emergency Drug Kit. If the medication was not stocked in the kit, an order would be sent to the pharmacy. The backup pharmacy was located in Indianapolis, and even stat orders took several hours to be delivered.
Blood Sugar Management Protocols Not Followed
Inspectors identified instances where nursing staff failed to follow physician-ordered protocols for managing residents' blood sugar levels. One resident with diabetes and Alzheimer's disease had physician orders specifying that if blood sugar readings fell to 60 mg/dL or below, staff should administer Baqsimi, a nasal powder used to treat hypoglycemia (low blood sugar).
The Medication Administration Records documented four occasions between December 2024 and February 2025 when this resident's blood sugar readings were at 60 mg/dL or below, including one reading of 57 mg/dL. There was no documentation that Baqsimi was administered for any of these readings.
Hypoglycemia at these levels can cause confusion, seizures, loss of consciousness, and if untreated, can be life-threatening. For a resident with Alzheimer's disease, recognizing and communicating symptoms of low blood sugar may be particularly difficult, making staff adherence to monitoring protocols especially important.
Similarly, another resident had orders for midodrine, a medication to raise blood pressure, when systolic readings fell below 110. The January 2025 medication record indicated 48 occasions when systolic blood pressure was below this threshold, and February 2025 showed 16 such occasions. While records showed staff appropriately held sotalol (a blood pressure-lowering medication) as ordered, there was no documentation that midodrine was administered as the physician had directed.
Infection Control Practices Found Deficient
The inspection revealed lapses in infection control practices related to respiratory equipment used by residents. For one resident with sleep apnea, inspectors observed over multiple dates that the CPAP mask was stored in a SoClean sanitizing machine that was not functioning, lacked a lid, and contained visible dust inside. Physician orders and the care plan specified the mask should be placed in the SoClean machine after removal for disinfection.
For two residents using supplemental oxygen, inspectors found oxygen tubing and nebulizer equipment stored improperly without protective bags and without date labels indicating when the equipment was last changed. One resident reported that staff had not changed her oxygen tubing or humidification bottle in over a month, despite physician orders specifying weekly replacement.
Proper maintenance of respiratory equipment is essential because contaminated equipment can introduce bacteria directly into the respiratory system. Patients requiring supplemental oxygen or CPAP therapy often have underlying respiratory conditions that make them more vulnerable to infections.
The Infection Prevention Nurse confirmed that oxygen administration equipment should be stored in bags when not in use. However, the facility's written policy on oxygen administration did not address equipment storage procedures.
Additional Issues Identified
Beyond the major violations detailed above, the inspection documented several other concerns:
- Documentation gaps: Multiple instances where physicians were not notified of missed medications, and records lacked explanations for why doses were not administered - Care plan implementation failures: Despite care plans specifying interventions such as regular showers and medication administration, staff were unable to consistently implement these plans - Policy deficiencies: The facility's staffing policy contained no specific information regarding required staffing levels or adjustments based on resident acuity - Weekend coverage problems: Multiple staff members specifically identified weekends as times of greatest staffing difficulty, with high rates of call-offs
The facility's resident population included individuals with significant care needs. According to documentation provided by the Director of Nursing, 40 residents required mechanical lifts for transfers, 21 required extensive assistance with hygiene and toileting, and 17 required feeding assistance at meals.
The inspection was completed on February 19, 2025, and was connected to multiple complaint investigations filed with the state. The Director of Nursing acknowledged the facility had experienced problems with the pharmacy supplying medications in a timely manner and stated that residents should have received their medications as ordered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Healthwin from 2025-02-19 including all violations, facility responses, and corrective action plans.
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