Holy Cross Rehab: Call Light Failures Leave Residents Waiting - IN
She had been waiting for help for over an hour.
Federal inspectors cited the facility following a complaint investigation completed September 17, 2025, documenting a pattern of failures to answer resident call lights and to resolve the grievances residents filed when no one came.
The family member of Resident G told inspectors that response times had been a persistent problem, and that the hour-long waits were not an isolated incident. The inspection record shows staff who worked during the period when Resident G was left sitting in soaked clothing received corrective actions. It does not say what those actions were, or whether anything changed.
Resident R had her own experience. Her call light was going unanswered, and when she investigated why, she found her nurse's pager had been left at the front desk, where the receptionist was watching it instead of the nurse carrying it. When Resident R raised the issue through the facility's grievance process, staff told her to make all her requests in a single trip, consolidating her needs so she would require less help. The resolution form noted she was not satisfied with that answer. She told the facility she planned to call 911 if response times exceeded 15 minutes.
A resident calling emergency services because a nursing home will not answer her call light is not a resolution. It is the absence of one.
Resident E had filed a grievance on July 25, 2025. The facility responded by holding an in-service training session on August 5, documented in its Education/In-service Record. The topic was activities of daily living care for residents. Inspectors reviewed the record and found it did not specifically indicate that any education on answering call lights had been provided. The training existed on paper. Whether it addressed the actual problem was a different question.
The Assistant Director of Nursing handed inspectors an undated policy on September 15, 2025, titled "Federal Resident Rights and Facility Responsibilities," and identified it as the current governing policy on resident rights. The policy stated that residents have the right to a dignified existence and self-determination, that the facility must treat each resident with respect and dignity, and that the facility must make prompt efforts to resolve grievances. The policy was undated. The inspection report does not indicate when it was last reviewed or updated.
What the policy described and what inspectors documented were not the same place.
The citation was classified as causing minimal harm or potential for actual harm, and inspectors noted it affected some residents. The language is federal regulatory shorthand. What it describes is a woman sitting in a chair with urine dripping off of it, a nurse's pager left at a reception desk, and a grievance process that told a resident to need less.
Resident G's family member had come to visit. That is how this came to light, because someone arrived and saw what the call light system was not preventing. The inspection record does not say how long Resident G had been sitting there before her family walked in.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Holy Cross Rehabilitation and Wellness from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
HOLY CROSS REHABILITATION AND WELLNESS in SOUTH BEND, IN was cited for violations during a health inspection on September 17, 2025.
She had been waiting for help for over an hour.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.