Holy Cross Rehab: Call Light Failures Left Residents Waiting - IN
The pattern began on July 24, when Resident E reported her call light had gone unanswered for more than two hours overnight. Staff were educated and in-serviced on response times. Six days later, a therapist arrived for a session and found Resident T's call light already on. The resident was very upset and said it had been on for hours that morning. The therapist observed the resident's CNA in a cubicle on a phone call before the session began and again after it ended.
On August 5, Resident R told therapy staff she had called the cops during the night because her call light wasn't working. Eight days later, she reported calling 911 again. The inspection record notes that by this point she was becoming delirious from sleep deprivation.
On August 8, a family member told the facility chaplain they had waited 45 minutes for a call light response, and the resident had been waiting to use the bathroom. When a CNA finally came, she turned off the light without completing the task.
On August 12, two more residents reported long waits. For one of them, Resident U, who said help took 25 to 30 minutes, the facility's own grievance record listed the action taken as: no action taken. That same day, Resident P waited one hour and five minutes. The CNA who hadn't answered was terminated.
When Resident G's family visited on August 29, they found her soaked in urine with urine dripping off her chair. Staff who worked that period received corrective actions.
An in-service record from August 5, created in response to the July complaint, covered general activities of daily living care. It did not specifically address call light response. Resident R, who had called 911 twice and remained unsatisfied with the facility's response, told staff she planned to call 911 again if her wait ever exceeded 15 minutes.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
HOLY CROSS REHABILITATION AND WELLNESS in SOUTH BEND, IN was cited for violations during a health inspection on September 17, 2025.
The pattern began on July 24, when Resident E reported her call light had gone unanswered for more than two hours overnight.
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.