Healthwin

F-F677 for additional information regarding Residents B, M, D, E, and 55

Findings include:

During a Resident/surveyor group meeting, conducted on 2/13/2025 at 1:41 P.M., 22 of 22 residents attending complained about untimely response to call lights, not receiving at least two showers a week and not receiving medications timely and/or not receiving all of their medications.

During a Family meeting with the new corporate representatives and the Director of Nursing, conducted on 2/12/2024 at 2 PM, several resident representatives complained about the lack of staffing to provide care, especially at night and residents not receiving timely showers or medications. The family representatives queried the new corporate staff and DON about reducing the number of staff and firing the QMAs (Qualified Medication Aides) and shower aides. The Director of Nursing informed the family members that the staff were not fired but were just not given as many work hours. The corporate representative informed the family members that the facility was staffed at a 3.5 PPD (hours of direct nursing care per resident per day) which was above the national average. The meeting ended abruptly when family members became emotional and loud after being told individual concerns would not be directly addressed during the meeting.

During an interview on 2/17/2025 at 11:18 A.M., the DON indicated the facility determined the staffing levels needed to meet each residents' needs each day based on acuity. The DON indicated in addition, during emergencies they used nursing staffing agencies and staff were allowed to pick up hours through their messaging service. She indicated the facility was staffed with a nursing supervisors every shift, 7 days a week. She indicated she had not received any staffing concerns from the families or residents until the newscasters had came to the facility. She did concede the nursing staff had voiced their concerns and the facility was trying to adjust to the new corporations staffing patterns.

Review of the Facility Assessment, provided on 2/17/2025 at 10:30 A.M. by the DON, regarding nursing staffing needs, dated 1/16/2025, indicated the following staffing needs: RN 14.8 (hours scheduled per day) LPN 18.6 (hours scheduled per day), CNA 63.5 per day (hours scheduled per day). Using this ratio for a census of 107 residents, the required, facility assessed PPD would be 6.79. However, after a discussion with

the DON, on 2/17/2025 at 1:38 P.M., a corrected facility assessment was provided which indicated the following nursing staff requirements: RN 5.38 (hours per day), LPN 12.55 (hours scheduled per day) and CNA 26.88 (hours scheduled per patient per day). This ratio, utilizing the current facility census of 98 residents equaled 3.42 PPD of nursing staff. It was unclear if any adjustments had been made to the PPD requirements due to resident acuity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 155153 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155153 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthwin Health & Rehabilitation 20531 Darden Rd South Bend, IN 46637

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 2/17/2025 at 1:30 P.M., the DON provided documentation of current resident needs. The form indicated

the following: 40 residents required the use of a mechanical lift to transfer, 21 residents required extensive Level of Harm - Minimal harm or assistance with personal hygiene and toileting needs and 17 residents required feeding assistance with their potential for actual harm meals.

Residents Affected - Many Review of the nursing schedules as worked from 1/20/2025 through 2/20/2025 indicated the facility failed to provide the assessed required staffing levels of 3.42 PPD on the following dates: 1/20, 1/21, 1/26, 2/1, 2/15 and 2/16/2025.

Although the staffing PPD scheduled was much higher than the 3.42 required staffing levels, the actual PPD for staff that had worked was much lower.

During an interview on 2/11/2025 at 2:21 P.M., CNA 5 indicated the facility used to have 3 CNA's on each unit, a nurse, a QMA that worked from 10:00 A.M. until 6:00 P.M., a shower aide and a restorative aide for

the day and evening shift, minus a shower aide on the evening shifts. He indicated now the facility only had two aides on the floor per unit and shower aide that worked a couple times a week, a restorative aide and a nurse for the day and evening shift He indicated the night shift had one CNA on all units. He indicated the residents had been complaining they had to wait longer for their call lights to be answered. He indicated they were understaffed and had to hurry and rush to provided the needed care. He indicated it was difficult to complete the scheduled showers.

During an interview on 2/17/2025 at 9:28 A. M., CNA 6 indicated she was assigned ten residents to get up and ready for breakfast by 8:30 A.M She indicated she did not have enough time to do extra things like nails, hair, showers and charting. She indicated the residents did not get showered unless there was a shower aide scheduled. She indicated she had only been able to pass ice water to four residents this morning. She indicated the weekends were worse because there were many staff that called off and did not show up for work. She indicated due to the lack of staffing, she had noticed there were now odors in the hallways. She was indicated she was often asked to pick up hours on her day off and asked stay over late. She indicated

she was suffering from burn out.

During an interview on 2/17/2025 at 12:05 P.M., CNA 17 indicated she was a shower aide 1-2 times a week.

She indicated when she worked on the floor and there were only two CNAs, she was assigned 10-11 residents. She indicated she had to work at a faster pace, and could not complete tasks such as nail care, showers and charting.

During an interview on 2/17/2025 at 1:56 P.M., CNA 15 indicated staffing the previous weekend did not go well. Sunday, he had worked on the a nursing unit by himself and had been assigned 14 residents. He indicated three of the 14 required feeding assistance in their rooms and by the tine he got done with breakfast trays, the lunch trays had arrived to the unit. The residents were so upset with him because their call lights were also not answered timely. He indicated he had only had time to check and change some residents and make sure they were comfortable. He indicated he had not had time to complete the four scheduled showers and had only completed half of his charting. He indicated residents that were usually continent had ended up wetting themselves because he could not assist them timely and they were very upset. CNA 15 indicated there was no time to wash everyone, do nail care, shave residents or provide oral care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 155153 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155153 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthwin Health & Rehabilitation 20531 Darden Rd South Bend, IN 46637

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 2/17/2025 at 2:40 P.M., CNA 14 indicated this past weekend, staffing was horrible.

She indicated she had only had time to provide one out of four scheduled showers on Saturday and none of Level of Harm - Minimal harm or the scheduled showers on Sunday. She had been assigned fourteen residents. She indicated she was potential for actual harm unable to complete the entire required assignment every day such as showers, charting and the little things that residents had requested. Residents Affected - Many

During an interview on 2/18/2025 at 10:48 A.M., CNA 2 indicated that he was assigned to care for 11 residents. He indicated he was unable to complete the following tasks:: showers, nail care, charting. He indicated he attempted to get everyone changed or toileted before he went home, but could not always accomplish it.

During an interview on 2/18/2025 at 11:00 A.M., CNA 7 indicated she was assigned to care for 11-12 residents and had problems getting the following tasks done: showers and charting.

During an interview on 2/17/2025 at 2:10 P.M., Resident K indicated she had to wait this past Sunday to use

the toilet. She indicated her back hurts when she had to hold it for too long. She indicated she had hardly seen the CNA working. She indicated she had ended up wetting the bed, which made her feel terrible. She had to ask her husband to help her with the bed pan because no staff had answered her call light. She indicated her husband had tried to help her but when he took her off the bedpan, it had spilled onto the bed and soiled the linens.

During an interview on 2/17/2025 at 2:21 P.M., Resident L indicated his care this past weekend was non-existent. He indicated it was like that every weekend. He indicated he had gone without fresh ice water all weekend, even though he had asked for it but no one had answered his call. When the aide had arrived,

the resident was informed the aide was the only one working and so the resident was unable to get out of bed, be washed up or dressed. He laid in his bed, in a gown, all weekend. Resident L indicated he had really wanted to get up on Sunday because he needed to have a BM. He indicated he had tried to hold it, for over

an hour but when help had finally arrived, he had an explosion in his brief and on the floor. He indicated he was so embarrassed about the accident.

During a interview on 2/17/2025 at 7:21 P.M., Resident C indicated that she had been at the facility for 5 weeks and had only received one shower. She indicated she was never offered a shower by the staff.

On 2/13/2025 at 9:00 A.M., a policy was requested for staffing and the DON provided a policy titled, Nursing Staffing Information Policy, undated and indicated the policy was the one currently used in the facility. The policy indicated .The facility will post nursing staffing information daily in a prominent place readily assessable to residents and visitors . There was no specific information in the policy regarding actual staffing requirements or adjustments to be made based on resident acuity levels.

3.1-17(a)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 155153 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155153 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthwin Health & Rehabilitation 20531 Darden Rd South Bend, IN 46637

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 49229

Residents Affected - Many Based on record review, interview and observation, the facility failed to ensure physician ordered medications were available for 6 of 13 residents whose medications were reviewed (Resident 86, L, M, N, O and Q) and failed to ensure medications were administered as ordered for 4 of 9 residents reviewed for quality of care. (Resident M, N, 47, 71)

Findings include:

1. During an observation, on 2/14/2025 at 10:30 A.M., Resident 86's resident representative was at the nursing station and asked RN 23 about the resident's Vancomycin (antibiotic). RN 23 informed the resident's representative that the pharmacy had not delivered the antibiotic yet.

During an observation, on 2/14/2025 at 11:10 A.M., RN 23 notified the nursing supervisor that the oral Vancomycin was not available for Resident 86.

During an interview, on 2/14/2025 at 1:54 P.M., RN 23 indicated the antibiotic (Vancomycin) for Resident 86 was ordered on the morning of 2/12/2025 and the pharmacy had not delivered it. RN 23 indicated she had called the pharmacy and the pharmacy indicated the antibiotic would be delivered on 2/14/2025.

During an interview, on 2/14/2025 at 2:10 P.M., RN 19 indicated the facility had an emergency drug kit (EDK) to pull medications, if needed, but oral Vancomycin was not included in the kit.

The clinical record of Resident 86 was reviewed on 2/18/2025 at 11:51 A.M. The resident's diagnoses included, but were no limited to: cerebral infarction, metabolic encephalopathy, diabetes mellitus, gastrointestinal hemorrhage, osteomyelitis, peripheral vascular disease, paroxysmal atrial fibrillation, morbid obesity, hypertension, heart failure, chronic kidney disease, neuromuscular dysfunction of bladder and osteomyelitis.

A 5-Day Minimum Data Set (MDS) assessment, dated 2/7/2025, indicated the resident was moderately cognitively impaired and was always incontinent of his bowels.

Current Physician Orders included but were not limited to:

-Clostridium difficile (C-diff) collection (stool sample) on 2/7/2025

-Vancomycin Hydrochloride oral capsule 125 milligrams (mg) (antibiotic) give one capsule by mouth every six hours for C-diff colitis for ten days, ordered on 2/12/2025.

A Lab Report, dated 2/12/2025, indicated a positive C-difficile Toxin [NAME] for Resident 86. Review of the lab report completed from the stool sample ordered on 2/7/2025 indicated the resident tested positive for a bowel infection, Clostridium difficile (C-Diff) The test results were dated 2/12/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 155153 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155153 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthwin Health & Rehabilitation 20531 Darden Rd South Bend, IN 46637

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Nursing Progress notes completed on the following dates and times indicated the resident's Vancomycin (antibiotic) had not yet been delivered from the pharmacy and could not be administered: Level of Harm - Minimal harm or potential for actual harm -2/13/2025 at 5:37 A.M.,

Residents Affected - Many -2/13/2025 at 12:11 P.M,

-2/13/2025 at 5:04 P.M.,

-2/14/2025 at 1:59 P.M., and

-2/14/2025 at 6:03 P.M.

There was no notation the physician had been notified of the delay in treatment, nor was there any documentation the pharmacy had been contacted regarding the need for the medication

The February 2025 Medication Administration Record (MAR) indicated Resident 86 did not receive his first dose of the Vancomycin (antibiotic) until 2/14/2025 at 11:00 P.M.

An Advanced Practice Provider Note, dated 2/13/2025, indicated the Nurse Practitioner had noted the resident was positive for C-Diff (bowel infection) and she had indicated the treatment had begun on 2/12/2025.

During an interview, on 2/19/2025 at 11:39 A.M., RN 3 indicated if an antibiotic was unavailable, then she would notify the pharmacy. If the pharmacy was unable to deliver the ordered medication, she would have tried to get the medication out of the EDK. If the EDK did not have the medication the resident needed, RN 3 indicated she would have notified the nursing supervisor of the missing dose of antibiotic.

During an interview, on 2/19/2025 at 1:59 P.M., LPN 24 indicated if there was a missing medication for a resident, she would have called the nursing supervisor to see if it was in the EDK. LPN 24 indicated if the medication was not in the Emergency Drug Kit, then she would have contacted the pharmacy. Lastly, LPN 24 indicated she would have notified the supervisor and updated the provider regarding the missing medication.

48145

2. Resident M's record review was completed on 2/18/2025 at 11:13 A.M. Diagnoses included, but were not limited to: paraplegia, sacral osteomyelitis, neuromuscular dysfunction of bladder and epilepsy.

A current Physician's order dated, 2/11/2025, indicated Resident M was to receive one gram ertapeneum (antibiotic) intravenously one time a day for sacral osteomyelitis from 2/11/2025 to 2/17/2025.

A February 2025 Medication Administration Record (MAR) indicated Resident M had not received her dose of ertapeneum on 2/13 and 2/16/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 155153 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155153 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthwin Health & Rehabilitation 20531 Darden Rd South Bend, IN 46637

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Resident M's record lacked the documentation she had refused her medication or a Physician had been notified that she had missed two doses of her medication. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/18/2025 at 2:15 P.M., the Director of Nursing indicated she was not sure why Resident M had missed two doses of ertapeneum, but Resident M should have received a dose of Residents Affected - Many ertapeneum on 2/13 and 2/16/2025.

3. Resident L's record review was completed on 2/18/2025 at 1:05 P.M. Diagnoses included but were not limited to: spinal stenosis, chronic obstructive pulmonary disease, heart failure and influenza type A.

A current Physician's order dated, 2/11/2025, indicated Resident L was to receive 75 milligrams of Tamiflu (antiviral) twice a day for 5 days due to the Influenza type A (flu) infection.

A February 2025 MAR indicated Resident L had not received either dose of the Tamiflu medication on 2/12/2025.

Resident L's record lacked the documentation he had refused his medication or a Physician had been notified that he had missed two doses of his medication.

4. Resident N's record review was completed on 2/19/2025 at 9:05 A.M. Diagnoses included, but were not limited to: neurogenic bowel, osteomyelitis of vertebra, urinary tract infection.

A current Physician's order dated, 2/10/2025, indicated Resident N was to receive 500 mg capsule of cephalexin (antibiotic) by mouth every eight hours for seven days for a urinary tract infection.

A February 2025 MAR indicated Resident N had not received his 1:00 P.M. dose of cephalexin on 2/10, 2/11 and 2/13/2025.

Nursing Progress notes, on 2/10 and 2/11 at 1:00 P.M. indicated the medication was not available to administer.

Resident N's record lacked the documentation a Physician had been notified that he had missed two doses of his cephalexin.

5. Resident O's record review was completed on 2/19/2025 at 10:15 A.M. Diagnoses included, but were not limited to: osteomyelitis, type two diabetes mellitus, hyperlipidemia and hypertension.

The current Physician's orders included the following medication orders:

-Admelog SoloStar Solution (Insulin pen) 1 unit at bedtime ordered on 2/4/2025

- daptomycin (antibiotic) one time a day IV ordered on 2/5/2024

- ergocalciferol (Vitamin D 2) one time a day orally ordered on 2/5/2024

- metformin (oral antidiabetic) one time a day orally ordered on 2/5/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 155153 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155153 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthwin Health & Rehabilitation 20531 Darden Rd South Bend, IN 46637

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 The February 2025 Medication Administration Record (MAR) indicated Resident O had not received a scheduled dose of Admelog SoloStar Solution on 2/4, 2/5 or 2/6/2025. Resident O had not received 500 mg Level of Harm - Minimal harm or of daptomycin intravenously on 2/5 or 2/13/2025. He also had not received 50000 units of ergocalciferol on potential for actual harm 2/5, 2/7, 2/8 or 2/9/2025 or his scheduled metformin on 2/4 or 2/18/2025.

Residents Affected - Many Resident O's record lacked the documentation he had refused his medications, or a Physician had been notified that he had missed a dose of his medications or the reason for the missed meditation.

During an interview on 2/19/2024 at 9:50 A.M., the Nursing Supervisor indicated the facility had been having difficulties obtaining prescriptions since the facility had switched pharmacies. She indicated if a medication was not available, the nurse was supposed to let the Nursing Supervisor know and the medication would have been obtained from the Emergency Drug Kit, if it was available. If the medication was not available, an order was sent to the pharmacy. The order would be sent as stat if the medication was anything other than a vitamin. The facility had a back-up pharmacy, but the Nursing Supervisor was unaware what the back up pharmacy's name was or how to contact the back-up pharmacy. She indicated if the main pharmacy was not able to fill the prescription timely, the main pharmacy contacted the back-up pharmacy. She indicated the back-up pharmacy was located in Indianapolis and it took several hours for prescriptions to be delivered even if they were ordered stat. In addition, she indicated if the resident misseds a dose of any medication,

the provider should have been notified.

During an interview on 2/19/2024 at 2:00 P.M., the Director of Nursing indicated the facility had had problems with their pharmacy supplying medications timely. She indicated residents should have received their medications as ordered and the provider should have been notified of any missed medications.

51598

6. A record review for Resident Q was completed on 2/18/2025 at 9:00 A.M. Diagnosis included but were not limited to osteomyelitis right foot/ankle, diabetes mellitus type 2, anxiety, depression, hypertension, and chronic kidney disease stage 3.

Physician orders included but were not limited to: ceftazidime 1.25 grams (gm) intravenously (IV) every 8 hours for osteomyelitis and tamiflu 75mg two times daily for 7 days for influenza.

A current care plan indicated Resident Q had Influenza A and interventions included but were not limited to administer oxygen as ordered, droplet isolation precautions, and check oxygen saturation as needed.

Resident Q's Medication Administration Record (MAR) for February 2025 indicated Tamiflu doses on 2/14/2025 were not administered and the order was not adjusted to account for the missed doses. In addition, it also indicated the ceftazidime 2.5mg, ordered on 2/7/2025 at 9:00 P.M., was not administerd 2/7/2025 through 2/10/2025.

A nursing medication note regarding the Tamiflu medication dated 2/14/2025 at 12:52 P.M. indicated the facility was still waiting for medication to arrive from pharmacy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 155153 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155153 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthwin Health & Rehabilitation 20531 Darden Rd South Bend, IN 46637

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 A nursing medication note for ceftazidime dated 2/08/2025 at 9:12 A.M., indicated the nurse had called pharmacy regarding the antibiotic and the pharmacist the medication would be delivered later the same night. Level of Harm - Minimal harm or potential for actual harm However, nursing medication notes on 2/9/2025 at 5:22 A.M., 2/10/2025 at 6:11 A.M., and 2/11/2025 at 8;23 A.M., all indicated the medication had not yet been delivered from pharmacy. Residents Affected - Many

During an interview, on 2/19/2025 at 11:00 A.M., RN 4 indicated the facility could request the medication stat and the pharmacy would decide if they would send the medication from backup pharmacy. She indicated the back up pharmacy was located in Indianapolis and it took several hours to obtain the medication from the back up pharmacy. She indicated the facility had not had pharmacy problems before the facility had switched over to the new pharmacy, the change has not been ideal and the new pharmacy was not on top of delivering ordered medications timely.

On 2/19/2025 at 1:50 P.M., the Director of Nursing indicated the pharmacy and backup pharmacy were both located in Indianapolis and orders took several hours to receive. She was not aware how to use the backup pharmacy but had been in contact with the main pharmacy and had been trying to switch the backup pharmacy to a local pharmacy.

7. A record review for Resident 47 was conducted on 2/17/2025 at 8:24 A.M. Diagnoses included but were not limited to: cerebral infarction, Alzheimer's, diabetes mellitis type 2, depression, and anxiety.

Physician orders included but were not limited to Insulin lispro (a fast acting diabetic medication) 100units/milliliter(ml)before meals, if 0 - 60 milligrams per deciliter (mg/dL) Administer nasal Baqsimi (a medication to increase blood sugar levels) and recheck BS in 15 mins; 61 - 149 = 0; 150- 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401+ = 10 notify MD/NP, Baqsimi nasal powder 3 milligrams/dose for hypoglycemia (low blood sugar).

A current care plan indicated Resident 47 had Diabetes. The interventions included but were not limited to diabetes medications as ordered, check blood sugar at 4:00 A.M. and offer snack if below 150, and consult doctor regarding any changes in diabetic medications.

The Medication Administration Record for December 2024 indicated Resident 47 had the following blood sugar readings: 12/6/2024 of 60 mg/dL, there was no documentation baqsimi was administered.

The Medication Administration Record for January 2025 indicated Resident 47 had the following blood sugar readings: 1/22/2025 of 60 mg/dL and 1/12/2025 of 57 mg/dL, there was no documentation baqsimi was administered for either of these readings.

The Medication Administration Record for February 2025 indicated Resident 47 had the following blood sugar readings: 2/15/2025 of 60 mg/dL, there was no documentation baqsimi was administered.

During an interview with LPN 19 on 2/18/2025 at 11:44 A.M., he indicated with a blood sugar reading equal to 60 mg/dL or less the facility was to administer baqsimi.

During an interview with the DON on 2/18/2025 at 12:00 P.M., she indicated with a blood sugar reading equal to or less than 60 mg/dL, staff should have administered baqsimi.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 155153 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155153 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthwin Health & Rehabilitation 20531 Darden Rd South Bend, IN 46637

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 8. A record review for Resident 71 was conducted on 2/13/2025 at 3:36 P.M. Diagnoses included but were not limited to: cancer head/face/neck, diabetes mellitus, depression, dysphagia, and heart disease. Level of Harm - Minimal harm or potential for actual harm Physician Orders included, but were not limited to: sotalol (medication for hypertension) 20 milligrams (mg) twice a day (BID) hold for systolic blood pressure (SBP) <110 and midodrine (medication for hypotension) 10 Residents Affected - Many mg as needed (PRN) for SBP<110.

Resident 71's current care plan indicated he had hypertension. Interventions, included but were not limited to: Check blood pressure per order, give medications as ordered, and observe for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness.

The medication administration record (MAR) for January 2025 indicated Resident 71's systolic blood pressure was below 110 on 48 occasions. The same MAR indicated the residents Sotolol was held as ordered, but did not indicate the resident received Midodrine as ordered.

The MAR for February 2025 indicated Resident 71's systolic blood pressure was below 110 on 16 occasions.

The same MAR indicated the residents Sotolol was held as ordered, but did not indicate the resident received Midodrine as ordered.

During an interview with LPN19 on 2/18/2025 at 11:44 A.M., he indicated if Resident 71 had a blood pressure reading under 110, the facility nurses should have administered midodrine.

During an interview with the DON on 2/18/2015, at 12:00 P.M., she indicated staff should have administered midodrine when the resident's systolic blood pressure reading was below 110.

A policy for pharmacy services was requested but one was not received before the exit of the survey.

This Federal tag relates to Complaint IN00451914, IN00451952, IN00452177, IN00451978, and IN00451284.

3.1-25(a)

3.1-25(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 155153