Healthwin Health & Rehabilitation

Inspectors wroteBased on observation interview, and record review, the facility failed to serve food at a palatable temperature for 1 of 4 nursing units. (West unit) This potentially affected 20 of 86 residents who ate food prepared in the kitchen. During an observation and temperature check of supper trays from a covered food cart, on the [NAME] 2 unit, on 4/21/2026 at 6:02 P.M., food was not served at a palatable temperature and the following temperatures were obtained:-the pureed grilled cheese was served at 125 degrees Fahrenheit.-the mashed potatoes and gravy was served at 128 degrees Fahrenheit. During an interview on 4/21/2026 at 6:02 P.M., the Dietary Director indicated the food should have been 135 degrees (Fahrenheit) at the point of service. On 4/22/2026 at 3:00 P.M. an undated policy titled, Food Preparation and Service was provided by the DON. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to prepare and serve food in a sanitary manner for 1 of 1 kitchens. This deficient practice potentially affected 82 out 86 residents who ate food prepared in the kitchen. During an initial tour and observation of the kitchen on 4/15/2026 at 9:42 A.M. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure bugs were controlled in 1 of 1 kitchen. During an observation of the kitchen on 4/17/2026 at 9:53 A.M., multiple dead bugs were noted in a light fixture above the 3-compartment sink used to wash food preparation utensils. During an interview on 4/17/2026 at 9:53 A.M. the DD indicated bugs were a problem and had been reported to the maintenance department but it had not yet been addressed. On 4/20/2026 at 10:25 A.M. a list of maintenance requests for the past 6 months was provided and the only issue listed was the peeling paint on kitchen ceiling tiles. On 4/22/2026 at 2:00 P.M. a policy regarding pest control was requested but one was not provided before survey exit. 410 IAC 16.2-3.1-19(f)(4)

Inspectors wroteBased on record review and interview, the facility failed to obtain informed consent for psychotropic medication administration for 1 of 5 residents reviewed for unnecessary medications. (Resident 3)

Inspectors wroteBased on interview and record review the facility failed to update a resident's care plan for 1 of 3 residents reviewed for falls. (Resident 16)

Inspectors wroteBased on interview, observation and record review, the facility failed to assess a resident after a fall for 1 of 3 residents reviewed for falls. (Resident 16)1. During an interview on 4/15/2026 at 10:42 A.M. Resident 16 indicated he had fallen several times and had gone to the emergency room twice as a result of the falls. During an observation on 4/15/2026 at 10:42 A.M. a fall mat was noted on the floor next to Resident 16's bed. A record review was completed on 4/27/2026 at 1:54 P.M. for Resident 16. Diagnoses included, but were not limited to, dementia and Parkinson's. An admission Minimum Data Set (MDS) assessment, dated 4/6/2026, indicated Resident 16 had a moderate cognitive deficit; required maximum assist for bathing and toileting and required moderate assist for bed mobility and transfers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure preventative measures were implemented for a resident with a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers.(Resident 10)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide gastrostomy tube (G-tube) care as ordered by the Physician for 1 of 1 resident who was observed for G-tube care. (Resident 17)

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained timely for 1 of 5 residents whose labs had been reviewed. (Resident 84)

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control practices were followed regarding emptying a urinal for 1 of 1 residents observed for urinal care. (Resident 40)

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive plan of care including a plan for type 2 diabetes, wound care and colostomy care was created for 1 of 3 residents reviewed for care plans. (Resident B)

Inspectors wroteBased on interview and record review the facility failed to ensure physician orders were in place for the treatment of low blood glucose, and failed to ensure the documentation was completed for wound care treatment according to physician orders, for 1 of 3 residents reviewed for diabetic management and wound treatment, (Resident B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a sufficient number of nursing staff to provide care to residents on all nursing units. This deficient practice had the potential to affect of residents. See F677 for additional information regarding Residents B, M, D, E, and 55

Inspectors wrote2. 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. 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. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure dependent residents received showers or complete bed baths as scheduled for 5 of 8 residents who were reviewed for showers or complete bed baths. (Residents B, M, D, E, and 55)

Inspectors wroteBased on observation, interview, and record review the facility failed to follow Physician orders related to tubi grips, and to failed to assess and treat an area of impaired skin for 2 of 12 residents reviewed for quality of care. (Residents J & 67) 1. During an interview on 2/11/2025 at 10:41 A.M., Resident J indicated she wore Tubi-grips to help with the swelling in her lower legs and feet. She indicated she could not put the Tubi-grips on by herself and staff had not regularly placed the Tubi-grips on her legs. During observations of Resident J, the resident was not wearing Tubi-grips (compression socks) on either leg and her right lower leg and foot were swollen: -2/11/2025 10:41 A.M. -2/12/2025 at 9:05 A.M. -2/13/2025 at 3:37 P.M. -2/14/2025 at 12:05 P.M. -2/17/2025 09:06 A.M. -2/17/25 2:01 P.M. Resident J's record review was completed on 2/17/2025 at 9:34 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from verbal abuse for 1 of 1 residents reviewed. (Resident 51)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident from free from a physical restraint for 1 of 1 residents reviewed for restraints. (Resident 67)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's allegation of verbal abuse was reported timely after an allegation was made to the Indiana Department of Health for 1 of 1 resident reviewed for abuse. (Resident 51)

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive plan of care included a plan to address an osteomyelitis diagnosis and the use of an indwelling catheter for 1 of 24 residents reviewed for comprehensive care plans. (Resident Q)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided with activities designed to meet their interest and their physical, mental, psychosocial well-being for 2 of 2 resident reviewed for activities. (Resident 55 and 83)

Inspectors wroteBased on interview and record review, the facility failed to ensure there were clinical indications to support the continued use of an indwelling catheter for 1 of 3 residents reviewed for catheters. (Resident Q)

Inspectors wroteBased on observation, interview and record review, the facility failed to follow Physician's orders related to enteral feedings for 1 of 1 resident reviewed for a gastronomy tube (G-tube) (Resident 46).

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a resident with a fractured arm apply her continuous positive airway pressure (CPAP) and clean the equipment after use for 1 of 1 residents reviewed for respiratory care. (Resident 23)

Inspectors wroteBased on observation, record review and interview, the facility failed to follow standards of practice for infection control for 3 of 4 residents who received supplemental oxygen or wore a CPAP (continuous positive airway pressure) machine at night. (Residents 27, 95 and 11)

Inspectors wroteBased on interview and record review, the facility failed to ensure a Hoyer Lift (a mechanical lift device) was used safely, by staff, for 1 of 3 residents reviewed for accidents. (Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was handled appropriately, foods were sealed appropriately, and foods were dated when opened. This had the potential to affect the 120 residents who receive meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan for 1 of 26 residents whose care plans were reviewed. (Resident 45)

Inspectors wroteBased on interview and record review, the facility failed to update a fall care plan with new interventions after a fall, for 1 of 3 residents reviewed for falls. (Resident 111)

Inspectors wroteBased on observation, record review, and interview, the facility failed to administer a PRN (as needed) diuretic medication per Physician's Orders, for 1 of 5 residents whose medication orders were reviewed. (Resident 174)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen equipment was stored appropriately and cleaned, for 2 of 3 residents reviewed for oxygen use. (Residents 8 & 83)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received person centered dementia care for 1 of 1 residents reviewed for dementia care. (Resident 6)

Inspectors wroteBases on observation, interview, and record review, the facility failed to properly label medications with the patient identification and date the medication was opened, for 3 medications found in 2 of 6 medication carts. (Northwest Cart 1 & East cart 1). The facility also failed to maintain a clean and sanitaty environment for medication storage to preserve medication integrity, for 1 of 6 medication carts observed. (Riverlane Cart)

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure, two of three residents, reviewed for falls were provided safe transfer assistance. This deficient practice resulted in significant injuries for both residents which required transfers to acute care centers for treatment. (Residents E and G)