Holy Cross Rehabilitation And Wellness
HOLY CROSS REHABILITATION AND WELLNESS in SOUTH BEND, IN — inspection on September 17, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
E indicated her call light had not gotten answered for over 2 hours on the night of 7/24/25.
The Action
resolution at that time.On 7/30/25, Therapy indicated Resident T's call light was on upon the
throughout the morning.
The resident's CNA was observed in the cubicle on a phone call before and after the therapy session.
The Action taken indicated that staff had spoken with the resident and reassured the resident that they would be watching the response times and had discussed the concern with the CNA. On 8/5/25, Resident R reported to the therapy department that she had not had help during the night so she had called the cops because her call light was not working and she needed help.
Actions taken indicated staff had not been aware of the long call-light issue and they had discussed the importance of having their pagers with them and checking the screen often.On 8/8/25, Resident S' family member reported to the Chaplin that they had waited 45 minutes for the call light to be answered and the resident had been waiting for a long time to go to the bathroom.
They indicated that the CNA had came into the room and turned off the light without completing the tasks.
Action taken indicated the facility had apologized for the delay in answering the call light and had spoken with the CNA and nurse.
They had checked both the pager and batteries and had assured resident and family they were addressing the concern.On 8/12/25, Resident U indicated it took 25 to 30 minutes to get help.
Action taken indicated there had been no action taken regarding the long call-light wait.On 8/12/25, Resident P indicated she had turned on the call-light and it was not answered for 1 hour and 5 minutes.
Action taken indicated the CNA who had not answered the light had been terminated.On 8/13/25 Resident R reported to therapy staff that she had called 911 during the night because the call light had not worked.
Action Taken indicated the call light was checked and it was functioning properly.
Guest did report she is becoming delirious from sleep deprivations.
Her complaint is more about sleep and wanting Ambien ordered.
The Resolution indicated the resident was not satisfied with the outcome.On 8/18/25, Resident R contacted the front desk and had informed them she had been waiting an hour to get cleaned up.
The receptionist indicated she looked at the nurse's pager and had not seen the resident's light on, and the CNA indicated she told Resident R that she would be back to clean her up when she had finished with another resident.
The receptionist indicated she observed many occasions when Resident R would use the call light as staff left her room.
The receptionist indicated staff had spoken to Resident R asking her to request all needs in one trip.
The Resolution indicated Resident R was not satisfied with the resolution and planned to call 911 if response times were greater than 15 minutes.
The form did not indicate why the nurse's pager had not been carried by the nurse and was left at the desk for the receptionist to view.On 8/29/25, Resident G's family member had indicated she and the resident were concerned about the call light response times and that the resident sometimes had to wait for over 1 hour for help.
The family member indicated she had come to visit and the Resident was soaked with urine and urine was dripping off of the resident's chair.
Action taken indicated staff working during that period had been given corrective actions.Review of an Education/In-service Record, dated 8/5/25 related to Resident E's concerns on a 7/25/25 Grievance, indicated the in-service topic were ADL care for residents. It had not specifically indicated education related to answering resident call-lights had been provided.On 9/15/25 at 3:30 P.M., the Assistant Director of Nursing provided an undated policy titled, FEDERAL RESIDENT RIGHTS & FACILITY RESPONSIBILITIES, and indicated that it was the current facility policy regarding resident rights.
The policy indicated, .The resident has a right to a dignified existence, self-determination.Dignity, Respect & Quality of Life. A facility must treat each resident with respect and dignity and care for each resident in a manner and in and environment that promotes maintenance or enhancement of his or her quality of life.Resolution of Grievances.
The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.This citation relates to Complaint 1232367.3.1-3(a)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.