Inspection Report
Re-Inspection
Census: 128
Capacity: 155
Deficiencies: 0
Jul 2, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to review Emergency Preparedness and Life Safety Code Recertification and State Licensure Survey compliance following prior surveys conducted on 05/05/25 and 05/06/25.
Findings
At this Post Survey Revisit, Hooverwood was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility was fully sprinklered with a fire alarm system and smoke detectors installed in all resident sleeping rooms and areas open to corridors.
Report Facts
Certified beds: 155
Census: 128
Inspection Report
Life Safety
Census: 129
Capacity: 155
Deficiencies: 18
May 6, 2025
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and 42 CFR Subpart 483.90(a).
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency power system maintenance, fire alarm system testing, sprinkler system inspections, fire drills, elevator firefighter recall testing, and electrical safety. Deficiencies were noted in documentation, maintenance, and physical conditions affecting safety.
Severity Breakdown
SS=F: 11
SS=E: 5
SS=D: 3
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing and maintenance requirements. | SS=F |
| Failed to maintain latching hardware on smoke barrier doors in basement. | SS=E |
| Failed to ensure corridor doors to hazardous areas were self-closing and not propped open. | SS=D |
| Failed to maintain fire alarm system testing and smoke detector sensitivity testing documentation. | SS=F |
| Failed to document sprinkler system inspections and control valve inspections as required. | SS=F |
| Failed to ensure corridor door to resident room 109 closed and latched properly. | SS=E |
| Failed to ensure smoke barrier doors closed to form a smoke resistant barrier in basement. | SS=D |
| Failed to maintain electrical junction box cover in safe operating condition. | SS=E |
| Soiled linen chute door missing and trash chute discharge room door propped open with stanchion. | SS=D |
| Failed to conduct semi-annual fire extinguisher inspections for some extinguishers. | SS=E |
| Failed to conduct quarterly fire drills for multiple shifts in several quarters. | SS=F |
| Failed to maintain documentation of electrical outlet receptacle testing for all resident sleeping rooms. | SS=F |
| Failed to ensure multi-plug adapter was not used as substitute for fixed wiring and extension cords used improperly. | SS=E |
| Failed to maintain monthly elevator firefighter recall testing documentation. | SS=E |
| Failed to maintain weekly inspections and monthly load testing documentation for emergency generator. | SS=F |
| Failed to conduct annual fuel quality test for diesel powered generator. | SS=F |
| Failed to provide documentation of 4-hour load test of emergency generator within past 36 months. | SS=F |
| Failed to maintain routine maintenance and testing records for emergency generator. | SS=F |
Report Facts
Certified beds: 155
Census: 129
Deficiencies cited: 19
Fire drills missing: 3
Weekly emergency generator inspections missing: 15
Sprinkler gauge inspections missing: 48
Sprinkler control valve inspections missing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Newcomer | Administrator | Named in relation to exit conference and findings review |
| Director of Maintenance | Named in relation to multiple findings, interviews, and corrective actions |
Inspection Report
Annual Inspection
Census: 19
Capacity: 151
Deficiencies: 9
Mar 26, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on March 20, 21, 24, 25 and 26, 2025.
Findings
The facility was found deficient in multiple areas including failure to complete self-medication administration assessments, failure to notify ombudsman and residents or representatives about transfers and discharges, failure to provide notice of bed hold policy, inadequate ADL care, unsafe transfer practices, incomplete monthly pharmacist medication reviews, failure to limit PRN psychotropic medications to 14 days and complete AIMS assessments, failure to serve meals at appropriate temperatures and failure to obtain resident or representative signatures on service plans.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure residents had self-medication administration assessments completed by the interdisciplinary team for 2 residents. | SS=D |
| Failed to ensure ombudsman and resident or representative were notified in writing of transfer and discharge reasons for 2 residents. | SS=D |
| Failed to provide notice of facility bed hold policy at time of transfer or within 24 hours for 5 residents. | SS=E |
| Failed to provide ADL care to prevent exposure and timely incontinence care for 1 dependent resident. | SS=D |
| Failed to ensure dependent resident was evaluated prior to transfer with sit-to-stand mechanical lift to ensure safe transfer. | SS=D |
| Failed to ensure residents' medications were reviewed monthly by pharmacist for 3 residents. | SS=D |
| Failed to limit PRN psychotropic medication to 14 days and complete AIMS assessments every 6 months for 2 residents. | SS=D |
| Failed to ensure resident was awakened when meal delivered so meal could be consumed at appetizing temperature. | SS=D |
| Failed to ensure service plans were signed by resident or representative for 3 residents. | — |
Report Facts
Survey dates: 5
Census total: 151
Current census: 19
Residents reviewed for transfer/discharge: 6
Residents reviewed for medication: 5
Residents reviewed for ADL care: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Newcomer | HFA, Administrator | Signed plan of correction letter |
| Becky Nash | BSN, RN, DON | Signed inspection report |
| Licensed Practical Nurse 6 | Interviewed regarding self-medication assessments | |
| Unit Manager 7 | Interviewed regarding self-medication assessments and transfer evaluations | |
| Unit Manager 10 | Observed and interviewed regarding resident transfer with mechanical lift | |
| Certified Nursing Assistant 8 | Interviewed regarding resident transfer and CNA assignment sheet | |
| Certified Nursing Assistant 9 | Interviewed regarding ADL care and resident brief changing | |
| Unit Manager 3 | Interviewed regarding meal delivery and resident preferences | |
| Certified Nursing Assistant 2 | Interviewed regarding meal delivery | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including medication reviews, meal delivery, and transfer practices |
| Assistant Director of Nursing | ADON | Interviewed regarding AIMS assessments and resident care |
| Executive Chef | Interviewed and observed regarding meal temperature | |
| Social Service Director | Interviewed regarding ombudsman notification |
Inspection Report
Renewal
Deficiencies: 0
Mar 26, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure survey.
Findings
The facility, Hooverwood, was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 143
Capacity: 162
Deficiencies: 3
Jan 22, 2025
Visit Reason
The visit was conducted for the investigation of multiple complaints (IN00445292, IN00446410, IN00446579, IN00449484, and IN00450262) regarding resident rights, accident hazards, and pharmacy services.
Findings
The facility was found deficient in ensuring residents were treated with respect and dignity, failed to ensure adequate supervision during Hoyer lift transfers to prevent accidents, and did not follow proper procedures for administering narcotic medications. All deficiencies were corrected prior to the survey start date and were considered past noncompliance.
Complaint Details
The investigation was triggered by complaints IN00445292, IN00446410, IN00446579, IN00449484, and IN00450262. Specific allegations included rough and disrespectful treatment by CNAs, inadequate supervision during resident transfers leading to falls, and failure to properly administer narcotic medications. The facility took corrective actions including terminating involved staff and in-servicing remaining staff.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure residents were treated with respect and dignity for 2 of 12 residents reviewed for resident rights. | SS=D |
| Failed to ensure two staff members completed a Hoyer lift transfer to prevent an accident for 1 of 3 residents reviewed for accidents. | SS=D |
| Failed to ensure a staff member followed the policy and procedure when administering narcotics to 2 of 7 residents reviewed for pharmaceutical services. | SS=D |
Report Facts
Residents reviewed for resident rights: 12
Residents reviewed for accidents: 3
Residents reviewed for pharmaceutical services: 7
Census: 143
Total licensed capacity: 162
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 10 | Agency Nurse | Placed on do not return list for failure to properly administer narcotic medications. |
| CNA 1 | Terminated for rough and disrespectful treatment of Resident J. | |
| CNA 5 | Terminated for mistreatment and yelling at Resident K. | |
| CNA 9 | Terminated for transferring Resident J with Hoyer lift without a second staff member. |
Inspection Report
Complaint Investigation
Census: 165
Deficiencies: 1
Dec 27, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00449779 regarding allegations of sexual abuse by a staff member.
Findings
The facility failed to protect a resident's right to be free from sexual abuse by a contracted housekeeping staff member. Immediate jeopardy was identified but removed after corrective actions were implemented, including staff interviews, resident evaluations, and termination of the employee.
Complaint Details
Complaint IN00449779 was substantiated with federal and state deficiencies cited related to the allegation of sexual abuse by a housekeeping staff member against Resident B.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect resident from sexual abuse by a staff member. | Immediate Jeopardy |
Report Facts
Census SNF/NF beds: 142
Census Residential beds: 23
Total Census beds: 165
Medicare census: 6
Medicaid census: 97
Other payor census: 39
Total census payor: 142
Employee verbal warnings: 2
Resident 15-minute checks: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 2 | Contracted Housekeeping Staff Member | Named in sexual abuse finding; observed committing abuse; terminated and arrested |
| Housekeeping Supervisor | Witnessed the abuse and intervened; reported incident to nursing staff and police | |
| Interim Executive Director | Interim Executive Director | Notified of immediate jeopardy; involved in corrective actions |
| Interim Director of Nursing | Interim Director of Nursing | Notified of immediate jeopardy; involved in corrective actions |
| RN 3 | Registered Nurse | Responded to incident report by Housekeeping Supervisor |
| LPN 4 | Licensed Practical Nurse | Assessed resident after incident; reported observations |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 168
Deficiencies: 3
Oct 11, 2024
Visit Reason
The visit was conducted for the investigation of complaints IN00442366, IN00443399, IN00443457, and IN00443672.
Findings
The facility was found deficient in ensuring residents were free from abuse, neglect, misappropriation of property, and maintaining resident-identifiable information confidentiality. Specific deficiencies included physical abuse of a resident with dementia, misappropriation of residents' personal property and credit card, and a breach of resident medication information privacy. All deficiencies were corrected prior to the survey start date and were considered past noncompliance.
Complaint Details
Complaints IN00442366 and IN00443399 had no deficiencies related to the allegations. Complaint IN00443457 involved a HIPAA breach related to resident-identifiable information. Complaint IN00443672 involved physical abuse of a resident. The facility was cited for deficiencies related to these complaints.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident was free from physical abuse related to a staff member pulling a resident's ears causing redness. | SS=D |
| Facility failed to ensure residents' personal property and credit card were kept safe and secure during admission for 2 residents. | SS=D |
| Facility failed to ensure a resident's medication list was kept private during admission, resulting in a HIPAA breach. | SS=D |
Report Facts
Census SNF/NF beds: 145
Census Residential beds: 23
Total Capacity: 168
Medicare Census: 7
Medicaid Census: 97
Other Census: 41
Number of residents reviewed for abuse: 4
Number of residents reviewed for misappropriation: 3
Date of abuse incident: Sep 19, 2024
Date of misappropriation incident: Aug 20, 2024
Date of credit card misuse: Aug 8, 2024
Date of HIPAA breach: Sep 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in physical abuse finding for pulling resident's ears; terminated for abuse |
| CNA 2 | Certified Nursing Assistant | Witnessed abuse by CNA 1 and reported it |
| LPN 4 | Licensed Practical Nurse | Observed redness on resident's ear and assessed resident after abuse report |
| CNA 5 | Certified Nursing Assistant | Terminated for theft of resident's airpods |
| LPN 8 | Licensed Practical Nurse | Involved in HIPAA breach by sending incorrect medication list |
| LPN 9 | Licensed Practical Nurse | Involved in HIPAA breach by sending incorrect medication list |
| Director of Nursing | Director of Nursing | Provided interviews and facility policies related to abuse, misappropriation, and HIPAA |
| Executive Director | Executive Director | Provided HIPAA education documentation |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 145
Deficiencies: 0
Jul 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438867.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00438867 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 10
Medicaid residents: 96
Other residents: 39
Inspection Report
Re-Inspection
Census: 142
Capacity: 155
Deficiencies: 2
Jul 3, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to previous surveys conducted on 05/31/24 and 04/04/24, specifically to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey.
Findings
At this PSR survey, Hooverwood was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility was fully sprinklered with fire alarm systems and smoke detectors installed in all resident sleeping rooms. No deficiencies were cited as the facility was found compliant.
Severity Breakdown
SS=F: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| HVAC heating, ventilation, and air conditioning shall comply with 9.2 and be installed in accordance with the manufacturer's specifications. | SS=F |
| Rubbish chutes, incinerators, and laundry chutes shall comply with provisions of Section 9.5, including automatic extinguishing protection and discharge into a trash collection room. | SS=E |
Report Facts
Certified beds: 155
Census: 142
Inspection Report
Re-Inspection
Census: 147
Capacity: 155
Deficiencies: 8
May 31, 2024
Visit Reason
Post Survey Revisit (PSR) to previous Life Safety Code and Emergency Preparedness surveys conducted on 04/04/2024 to verify correction of cited deficiencies.
Findings
The facility was found not in compliance with Emergency Preparedness requirements, Life Safety Code, and other regulatory standards including generator maintenance, fire alarm system testing, fire damper inspections, and door locking mechanisms. Several deficiencies from the prior survey were not corrected and systemic plans of correction were required.
Severity Breakdown
SS=F: 7
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements per NFPA 110 and Life Safety Code. | SS=F |
| Failed to maintain fire alarm system in accordance with NFPA 72; semi-annual inspections not documented or incomplete. | SS=F |
| Failed to ensure means of egress door was readily accessible without improper locking or signage. | SS=E |
| Failed to ensure fire dampers were inspected and maintained every 4 years per NFPA 90A and NFPA 80. | SS=F |
| Trash chute door failed to be self-closing and positively latching as required by NFPA 82. | SS=E |
| Failed to maintain written records of weekly emergency generator inspections for 4 weeks of the most recent 52 week period. | SS=F |
| Failed to exercise emergency generator monthly for 1 of 12 months as required by NFPA 110. | SS=F |
| Building construction type not maintained for new construction in sprinkler riser room; hole in ceiling exposing underside of second floor decking. | SS=F |
Report Facts
Certified beds: 155
Census: 147
Deficiency citation date: 2024
Fire damper inspection scheduled date: 2024
Trash chute door parts expected delivery: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Voss | Administrator | Signed report and involved in exit conferences. |
Inspection Report
Re-Inspection
Census: 146
Capacity: 164
Deficiencies: 0
Apr 16, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the Investigation of Nursing Home Complaint IN00425592 completed on March 6, 2024.
Findings
Hooverwood was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the Investigation of Complaint IN00425592.
Complaint Details
Complaint IN00425592 was investigated and found to be corrected.
Report Facts
Census SNF/NF: 146
Census Residential: 18
Total Capacity: 164
Census Medicare: 12
Census Medicaid: 93
Census Other: 41
Total Census Payor Type: 146
Inspection Report
Life Safety
Census: 142
Capacity: 155
Deficiencies: 12
Apr 4, 2024
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency power system maintenance, fire alarm system testing, fire extinguisher accessibility, trash chute door latching, fire drills, fire door inspections, electrical receptacle testing, fire damper inspections, sprinkler system installation, building construction type, and egress door locking arrangements.
Severity Breakdown
SS=F: 9
SS=E: 2
SS=D: 1
: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; missing weekly and monthly load testing documentation. | SS=F |
| Failed to maintain fire alarm system in accordance with NFPA 72; missing semi-annual inspection documentation. | SS=F |
| Failed to ensure 1 of 52 fire extinguishers was accessible at all times; extinguisher blocked by podium and stacked chairs. | SS=E |
| Trash chute discharge room door lacked positive latching mechanism; door failed to latch properly. | SS=D |
| Failed to conduct quarterly fire drills on all shifts and failed to document staff participation for one third shift fire drill. | SS=F |
| Failed to ensure annual inspection and testing of all fire door assemblies; missing itemized listing and documentation. | SS=F |
| Failed to ensure documentation of electrical outlet receptacle testing for all resident sleeping rooms was available for review. | SS=F |
| Failed to ensure all fire dampers were inspected and maintained at least every four years; missing documentation and inspection date. | SS=F |
| Failed to ensure weekly inspection and monthly exercising of emergency generator was documented for all required weeks; missing documentation for several weeks and one month load test. | SS=F |
| Failed to ensure means of egress door at 1B lounge was secured with a delayed egress locking system and exit code was not posted at courtyard exit gate. | — |
| Missing drywall in sprinkler riser room ceiling exposing underside of second floor decking. | SS=F |
| Sprinkler riser room closet missing an automatic sprinkler to ensure coverage. | SS=F |
Report Facts
Certified beds: 155
Census: 142
Fire extinguishers: 52
Fire drills missing: 5
Fire door inspection frequency: 12
Fire damper inspection frequency: 4
Generator weekly inspections missing: 4
Generator monthly load test missing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Voss | Administrator | Named in relation to exit conference and findings review |
Inspection Report
Recertification
Census: 19
Deficiencies: 12
Mar 6, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of Nursing Home Complaints IN00420378, IN00425592, and IN00428227.
Findings
The facility was cited for multiple deficiencies including failure to ensure proper medication administration and self-administration assessments, incomplete PASARR Level II documentation, inadequate resident-specific interventions for activities of daily living and communication, lack of ongoing cognitively stimulating activities for residents with dementia, failure to provide quality care including proper choking response and resident positioning, improper medication storage and labeling, unsafe food storage practices, and infection control lapses including improper PPE use and hand hygiene.
Complaint Details
Complaint IN00420378 - No deficiencies related to the allegations are cited. Complaint IN00425592 - Federal/State deficiencies related to the allegations are cited at F676, F677, F679 and F684. Complaint IN00428227 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 6
SS=E: 3
SS=G: 1
: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure a resident had a self-medication administration assessment and medications were not left unattended in a resident's room. | SS=D |
| Failed to ensure PASARR Level II was recorded on the Minimum Data Set for residents with mental disorders. | SS=D |
| Failed to develop and implement resident specific interventions to address communication limitations for a resident who spoke Russian. | SS=D |
| Failed to develop and implement resident specific interventions to meet grooming, bathing, and clothing needs for a cognitively impaired resident with a history of elder abuse. | SS=D |
| Failed to ensure ongoing program of cognitively stimulating activities for residents diagnosed with dementia. | SS=E |
| Failed to ensure services were provided to effectively administer back blows for a choking resident and failed to revise care plan with accurate care information; failed to ensure residents maintained upright positioning; failed to notify physician for blood sugars above parameters and to complete daily weights as ordered. | SS=G |
| Failed to ensure residents received adequate supervision and interventions to prevent falls and failed to determine root cause or implement new interventions after falls. | SS=D |
| Failed to label oxygen tubing and administer correct oxygen flow for residents receiving respiratory care. | SS=D |
| Failed to ensure medications were stored according to pharmacy directions, labeled and dated, and schedule II medication cards were not compromised. | SS=E |
| Failed to keep stored food items covered in cold storage room for safe and sanitary conditions. | SS=D |
| Failed to ensure a resident's medication was locked and secured for a resident who self-administered medications. | — |
| Failed to ensure infection control practices including use of PPE, hand hygiene, equipment disinfection, and proper catheter bag placement for residents with transmission based precautions. | SS=E |
Report Facts
Survey dates: 2024-02-27 to 2024-03-06
Census: 19
Deficiencies cited: 11
Blood sugar levels: 399
Blood sugar levels: 385
Blood sugar levels: 358
Missing daily weights: 46
Loose pills: 17
Compromised medication card slots: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Voss | Administrator | Signed the report |
| RN 14 | Nurse involved in medication administration deficiency for Resident 99 | |
| Unit Manager (2A UM) | Provided interview regarding medication administration for Resident 99 | |
| RN 12 | Provided interview regarding medication administration for Resident 99 | |
| Director of Nursing (DON) | Provided interview regarding medication administration for Resident 99 | |
| Social Services Director (SSD) | Provided interview regarding PASARR documentation | |
| Assistant Director of Nursing (ADON) | Received facility policies and provided interview | |
| Certified Nursing Aide (CNA) 5 | Observed and interviewed regarding communication deficiency for Resident K | |
| Qualified Medication Aide (QMA) 6 | Interviewed regarding communication deficiency for Resident K | |
| Speech Therapist (ST) 10 | Interviewed regarding swallowing and choking incident for Resident S | |
| Unit Manager (UM) 8 | Interviewed regarding choking incident for Resident S | |
| CNA 9 | Involved in Heimlich maneuver for Resident S | |
| RN 15 | Interviewed regarding choking incident for Resident S | |
| CNA 17 | Witnessed choking incident for Resident S | |
| CNA 21 | Witnessed choking incident for Resident S | |
| CNA 20 | Witnessed choking incident for Resident S | |
| RN 16 | Witnessed choking incident for Resident S | |
| UM 22 | Witnessed choking incident for Resident S | |
| LPN 11 | Observed medication cart on 2A west | |
| LPN 17 | Observed medication cart on 2B east | |
| LPN 18 | Observed medication cart on 2B west | |
| RN 12 | Interviewed regarding oxygen tubing | |
| LPN 2 | Interviewed regarding infection control for Resident Q | |
| CNA 3 | Interviewed regarding infection control for Resident Q | |
| LPN 1 | Interviewed regarding infection control for Resident Q | |
| Social Services 23 | Observed in Resident 14's room | |
| Unit Manager 8 | Interviewed regarding infection control and isolation gown use | |
| Assistant Director of Nursing Services (ADNS) | Interviewed regarding infection control policies and gown reuse | |
| Dietary Manager 25 | Interviewed regarding food storage and safety | |
| CNA 25 | Observed stepping on fall mattress | |
| CNA 13 | Interviewed regarding oxygen tubing | |
| RN 24 | Interviewed regarding CPR training and choking protocol | |
| Activity Director | Interviewed regarding activity programming for residents with dementia |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 15, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00419026 completed on October 12, 2023.
Findings
Hooverwood was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00419026 was completed with findings of compliance.
Report Facts
Complaint Investigation ID: 419026
Inspection Report
Complaint Investigation
Census: 149
Capacity: 149
Deficiencies: 2
Oct 12, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00419026 regarding medication administration errors and labeling deficiencies.
Findings
The facility failed to ensure residents were free of significant medication errors for 3 of 6 residents reviewed, including wrong insulin administration, incorrect medication hold orders, and improper application of fentanyl patches. Additionally, medication labels were found inaccurate for 1 of 5 residents reviewed during medication administration.
Complaint Details
Complaint IN00419026 - Federal/State deficiencies related to the allegations are cited at F760 and R301.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents were free of significant medication errors for 3 of 6 residents reviewed for medication administration (Residents B, C, and D). | SS=D |
| Failed to have accurate labels on medications for 1 of 5 residents reviewed during medication administration (Resident 4). | — |
Report Facts
Residents reviewed for medication administration: 6
Residents reviewed for medication labeling: 5
Census: 149
Total licensed capacity: 149
Medicare census: 14
Medicaid census: 97
Other payor census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Voss | Administrator | Signed the report and plan of correction. |
| RN 3 | Registered Nurse | Administered wrong insulin to Resident B and participated in insulin education. |
| LPN 2 | Licensed Practical Nurse | Involved in fentanyl patch medication error and educated on medication policy. |
| LPN 4 | Licensed Practical Nurse | Observed preparing medications with inaccurate labels for Resident 4. |
| Director of Nursing | Provided education, interviews, and documentation related to medication errors and labeling. | |
| Assistant Director of Nursing | Signed employee communication form related to medication administration. |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 147
Deficiencies: 0
Aug 29, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00415471 and IN00415220.
Findings
No deficiencies related to the allegations in complaints IN00415471 and IN00415220 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00415471 and Complaint IN00415220 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type: 147
Medicare Census: 15
Medicaid Census: 100
Other Payor Census: 32
Inspection Report
Re-Inspection
Census: 146
Capacity: 146
Deficiencies: 0
Aug 16, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the unrelated deficiency cited during the Investigation of Complaints IN00412984 and IN00412833 completed on July 17, 2023.
Findings
Hooverwood was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the unrelated deficiencies cited during the Investigation of Complaints IN00412984 and IN00412833.
Report Facts
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 101
Census Payor Type - Other: 33
Inspection Report
Complaint Investigation
Census: 145
Capacity: 145
Deficiencies: 1
Jul 17, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00412984 and IN00412833. Both complaints resulted in no deficiencies related to the allegations, but an unrelated deficiency was cited.
Findings
The facility failed to protect a resident (Resident 2) from injury during a transfer when a CNA did not follow transfer instructions, resulting in a femur fracture. The resident was transferred by one staff instead of two with a gait belt as required, leading to a fall and injury. The facility has planned corrective actions including education and updated care plans to prevent recurrence.
Complaint Details
Complaint IN00412984 and Complaint IN00412833 were investigated. No deficiencies related to the allegations of either complaint were cited.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect Resident 2 from injury during transfer when CNA did not follow transfer instructions, resulting in a femur fracture. | G |
Report Facts
Census: 145
Total Capacity: 145
Medicare Census: 9
Medicaid Census: 97
Other Payor Census: 39
Date of Fall Incident: Jun 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Voss | Administrator | Signed the report |
| CNA 1 | Named in deficiency for improper transfer of Resident 2 | |
| LPN 2 | Licensed Practical Nurse | Assessed Resident 2 after fall and transfer |
| TX 3 | Therapy Staff | Provided information on Resident 2 transfer requirements |
| Assistant Director of Nursing | Provided CNA assignment sheet and interviewed CNA 1 |
Inspection Report
Follow-Up
Census: 139
Capacity: 155
Deficiencies: 0
Apr 14, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code surveys conducted earlier in the year.
Findings
At this PSR survey, Hooverwood was found in compliance with Emergency Preparedness Requirements and Life Safety Code regulations, including full sprinklering and fire alarm systems throughout the facility.
Report Facts
Certified beds: 155
Census: 139
Inspection Report
Re-Inspection
Census: 138
Capacity: 155
Deficiencies: 6
Mar 1, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 01/19/23 to verify correction of previous deficiencies.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards including deficiencies in emergency power system testing and maintenance, fire alarm system maintenance, and electrical equipment use in patient care areas. Corrective actions were initiated but full compliance was not yet achieved at the time of this revisit.
Severity Breakdown
SS=F: 4
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; incomplete monthly load testing documentation; emergency generator load testing did not achieve minimum 30% load; missing 36-month continuous load test documentation. | SS=F |
| Fire alarm system was in trouble mode for at least a couple months due to control board and battery charging issues; repairs pending. | SS=F |
| Failed to maintain fire alarm system in accordance with NFPA 70 and NFPA 72 standards. | SS=F |
| Failed to ensure emergency generator exercised monthly and annually per NFPA 110 standards. | SS=F |
| Failed to document 36-month period emergency generator testing for four continuous hours as required. | — |
| Power strips and electrical receptacles in lamps in patient care vicinity used as substitute for fixed wiring, contrary to NFPA 70 and Life Safety Code requirements. | SS=E |
Report Facts
Certified beds: 155
Census: 138
Deficiencies cited: 5
Emergency generator load test date: 2023
Scheduled repair date: 2023
Inspection Report
Re-Inspection
Census: 159
Deficiencies: 0
Feb 2, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Investigation of Complaints IN00385997 and IN00394199 completed on December 21, 2022.
Findings
Hooverwood was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and Investigation of Complaints IN00385997 and IN00394199. Both complaints were corrected.
Complaint Details
Complaint IN00385997 and Complaint IN00394199 were investigated and found to be corrected.
Report Facts
Census Bed Type - SNF/NF: 145
Census Bed Type - Residential: 14
Total Census: 159
Census Payor Type - Medicare: 15
Census Payor Type - Other: 130
Total Census Payor: 145
Inspection Report
Life Safety
Census: 138
Capacity: 155
Deficiencies: 11
Jan 19, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements related to emergency power system inspection, testing, and maintenance. Life Safety Code deficiencies included incomplete annual fire door inspections, obstructed means of egress, improper door locking arrangements, failure to maintain elevator firefighter recall testing documentation, failure to maintain fire damper inspections, emergency annunciator panel malfunction, incomplete emergency generator testing and documentation, and improper use of power strips in patient care areas.
Severity Breakdown
SS=F: 7
SS=E: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to implement emergency power system inspection, testing, and maintenance requirements per NFPA 110 and Life Safety Code. | SS=F |
| Failure to ensure annual inspection and testing of all fire door assemblies in accordance with LSC 19.1.1.4.1.1. | SS=F |
| Failure to maintain means of egress free of obstructions; a plastic chest of drawers was stored in a corridor. | SS=E |
| Failure to ensure door locking arrangements comply with clinical needs or security threat locking requirements; exit door code not posted. | SS=E |
| Failure to ensure fire damper inspections and maintenance at least every four years per NFPA 90A and NFPA 80. | SS=E |
| Failure to maintain monthly testing documentation of elevator firefighter recall as required by ASME A17.1/CSA B44. | SS=E |
| Emergency generator remote annunciator panel not in proper operating condition; 'Low Coolant Temp' trouble light illuminated. | SS=F |
| Failure to maintain weekly emergency generator inspection documentation for 28 weeks of the most recent 52 week period. | SS=F |
| Failure to document monthly load testing for six months and annual load bank testing for emergency generator as required by NFPA 110. | SS=F |
| Failure to document 36 month period emergency generator testing for four continuous hours as required by NFPA 110. | SS=F |
| Use of power strips in patient care vicinity as substitute for fixed wiring; CPAP and oxygen concentrator plugged into lamp stand receptacles. | SS=E |
Report Facts
Certified beds: 155
Census: 138
Emergency generator rating: 800
Weekly emergency generator inspection documentation missing: 28
Elevators: 2
Residents potentially affected by obstructed egress: 15
Residents potentially affected by door locking issue: 20
Residents potentially affected by power strip misuse: 20
Residents potentially affected by elevator recall testing deficiency: 6
Inspection Report
Routine
Census: 160
Deficiencies: 15
Dec 12, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of complaints IN00394199, IN00382714, and IN00385997.
Findings
The facility was cited for multiple deficiencies including failure to notify physicians of medication changes, incomplete care plans, inadequate ADL assistance, medication administration errors, pressure ulcer care deficiencies, unsafe chemical storage, infection control lapses, improper medication storage, food safety violations, and failure to provide required immunizations.
Complaint Details
Complaint IN00394199 - Substantiated with deficiencies cited at F580. Complaint IN00382714 - Unsubstantiated due to lack of evidence. Complaint IN00385997 - Substantiated with deficiencies cited at F677.
Severity Breakdown
SS=D: 9
SS=G: 2
SS=E: 3
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to notify physician and responsible party when Tacrolimus medication was not given or available for Resident 21. | SS=D |
| Failed to develop and implement a comprehensive care plan for Resident 50 with osteogenesis imperfecta. | SS=D |
| Failed to provide assistance with ADLs related to nail care for Resident 21. | SS=D |
| Failed to provide necessary care and services for Resident 21 and Resident 9 related to medication administration and bowel protocol. | SS=D |
| Failed to ensure pressure ulcer care and treatment consistent with professional standards for Residents 299, 21, and 112. | SS=G |
| Failed to ensure kitchenettes cleaning chemicals were locked and secured away in a cabinet (Unit 2B). | SS=D |
| Failed to ensure residents with indwelling catheters received appropriate catheter care and timely catheter changes for Residents 21 and 86. | SS=G |
| Failed to ensure oxygen tubing was changed weekly and residents received oxygen at the correct ordered liter flow for Residents 24 and 48. | SS=D |
| Failed to ensure blood sugar was taken and insulin administered per physician's orders and failed to ensure pain was assessed by a licensed nurse prior to QMA administering pain medication for Resident 120. | SS=D |
| Failed to ensure psychotropic medication for Resident 50 had an appropriate diagnosis and was monitored for side effects. | SS=D |
| Failed to ensure oral medications were stored separately from eye and ear medications, medications were stored in packaging, and labeled with open dates on medication carts 1A East, 2B, and 2A. | SS=D |
| Failed to properly handle and store potentially hazardous foods, maintain kitchen equipment and areas, and label and date refrigerated products in the main kitchen and 2 of 4 kitchenettes. | SS=E |
| Failed to follow CDC guidelines to prevent transmission of MRSA, failed to implement infection control precautions during meal service for resident with active cough and influenza A, and failed to properly disinfect blood spills in resident rooms. | SS=E |
| Failed to provide documentation of fire department involvement in fire drills every six months. | — |
| Failed to ensure residents received pneumococcal immunization after consent was obtained for Resident 303. | — |
Report Facts
Survey dates: 7
Residents on SNF/NF beds: 146
Residents on Residential beds: 14
Total residents: 160
Medicare residents: 9
Medicaid residents: 97
Other payor residents: 40
Total payor residents: 146
Fire drills required per year: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Voss | Administrator | Signed report on 01/21/2023 |
| LPN 15 | Licensed Practical Nurse | Observed providing wound care to Resident 21 |
| LPN 12 | Licensed Practical Nurse | Interviewed about oxygen therapy and catheter care |
| QMA 10 | Qualified Medication Aide | Interviewed about medication cart cleaning and medication administration |
| ADON | Assistant Director of Nursing | Interviewed about multiple findings including medication, catheter care, and infection control |
| DON | Director of Nursing | Interviewed about catheter care and medication administration |
| Consulting Pharmacist | Interviewed about medication billing and communication errors | |
| Nurse Educator | Interviewed about care for Resident 50 and blood on floor | |
| Dietary Aide | Interviewed about chemical storage | |
| Registered Dietitian | Interviewed about chemical storage and kitchen cleanliness | |
| Kitchen Manager | Interviewed about chemical storage and kitchen cleanliness | |
| Corporate Environmental Service and Maintenance Director | Interviewed about chemical storage | |
| Corporate Kitchen Support | Interviewed about food storage and kitchen cleanliness | |
| Quality Assurance Coordinator | Interviewed about oxygen therapy and fire drills |
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