Deficiencies (last 4 years)
Deficiencies (over 4 years)
38.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
817% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
83% occupied
Based on a July 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a resident with dementia exited the secured locked unit unsupervised, posing immediate jeopardy to resident health and safety.
Complaint Details
The investigation was triggered by a complaint regarding Resident B's elopement on 12/23/25. The resident exited the secured unit unsupervised, was found walking down the road approximately 0.4 miles away, and was unharmed. The complaint was substantiated with findings of inadequate door security and staff response.
Findings
The facility failed to ensure a resident at risk for elopement did not exit the facility unsupervised due to an unlocked stairway door and an exit door that was alarmed but not locked. Staff responded to the door alarm but did not properly investigate, resulting in the resident wandering outside unsupervised. The facility's elopement policy lacked clear staff response procedures for door alarms.
Deficiencies (1)
F 0689: The facility failed to ensure a resident with dementia on a secured locked unit did not exit unsupervised due to an unlocked stairway door and an exit door that was alarmed but not locked. Staff reset the door alarm without investigating, allowing the resident to wander outside unsupervised.
Report Facts
Residents reviewed for accidents: 3
Residents affected: Few residents affected as stated
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding door security and incident response |
| CNA 2 | Certified Nursing Assistant | Found Resident B walking down the road |
| LPN 7 | Licensed Practical Nurse | Responded to door alarm and reset it without investigating outside |
| LPN 8 | Licensed Practical Nurse | Responded to door alarm and reset it without investigating outside |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of neglect and misappropriation of property at the nursing home.
Complaint Details
The complaint involved neglect of incontinence care for Resident E and misappropriation of narcotic medication for Resident C. Both complaints were substantiated and corrective actions including staff termination and re-education were taken.
Findings
The facility was found to have failed to provide adequate incontinence care to a dependent resident and failed to prevent narcotic medication theft by an employee. Both deficient practices were corrected prior to the survey date.
Deficiencies (2)
F 0600: The facility failed to ensure a dependent resident was free from neglect and provided incontinence care during an eight-hour shift. The issue was corrected prior to the survey.
F 0602: The facility failed to ensure narcotic medications were free from theft by an employee for one resident. The issue was corrected prior to the survey.
Report Facts
Residents reviewed for neglect: 3
Residents reviewed for misappropriation: 3
Dates of deficient practice correction: Incontinence care neglect corrected on 2025-06-26; narcotic theft corrected on 2025-12-17.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Named in neglect of incontinence care finding and terminated. |
| RN 6 | Registered Nurse | Named in narcotic medication theft finding and terminated. |
| CNA 3 | Certified Nursing Assistant | Reported neglect of Resident E's incontinence care. |
| LPN 1 | Licensed Practical Nurse | Reported narcotic medication discrepancy. |
| LPN 4 | Licensed Practical Nurse | Reported narcotic medication discrepancy. |
| RN 5 | Registered Nurse | Provided interview on medication documentation policies. |
| Director of Nursing | Director of Nursing | Interviewed regarding neglect and narcotic theft complaints. |
Inspection Report
Re-Inspection
Census: 128
Capacity: 155
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (18)
Failed to implement emergency power system inspection, testing and maintenance requirements.
Failed to maintain latching hardware on smoke barrier doors in basement.
Failed to ensure corridor doors to hazardous areas were self-closing and not propped open.
Failed to maintain fire alarm system testing and smoke detector sensitivity testing documentation.
Failed to document sprinkler system inspections and control valve inspections as required.
Failed to ensure corridor door to resident room 109 closed and latched properly.
Failed to ensure smoke barrier doors closed to form a smoke resistant barrier in basement.
Failed to maintain electrical junction box cover in safe operating condition.
Soiled linen chute door missing and trash chute discharge room door propped open with stanchion.
Failed to conduct semi-annual fire extinguisher inspections for some extinguishers.
Failed to conduct quarterly fire drills for multiple shifts in several quarters.
Failed to maintain documentation of electrical outlet receptacle testing for all resident sleeping rooms.
Failed to ensure multi-plug adapter was not used as substitute for fixed wiring and extension cords used improperly.
Failed to maintain monthly elevator firefighter recall testing documentation.
Failed to maintain weekly inspections and monthly load testing documentation for emergency generator.
Failed to conduct annual fuel quality test for diesel powered generator.
Failed to provide documentation of 4-hour load test of emergency generator within past 36 months.
Failed to maintain routine maintenance and testing records for emergency generator.
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
Date: 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.
Deficiencies (9)
Failed to ensure residents had self-medication administration assessments completed by the interdisciplinary team for 2 residents.
Failed to ensure ombudsman and resident or representative were notified in writing of transfer and discharge reasons for 2 residents.
Failed to provide notice of facility bed hold policy at time of transfer or within 24 hours for 5 residents.
Failed to provide ADL care to prevent exposure and timely incontinence care for 1 dependent resident.
Failed to ensure dependent resident was evaluated prior to transfer with sit-to-stand mechanical lift to ensure safe transfer.
Failed to ensure residents' medications were reviewed monthly by pharmacist for 3 residents.
Failed to limit PRN psychotropic medication to 14 days and complete AIMS assessments every 6 months for 2 residents.
Failed to ensure resident was awakened when meal delivered so meal could be consumed at appetizing temperature.
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
Date: 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
Routine
Deficiencies: 8
Date: Mar 26, 2025
Visit Reason
Routine inspection of Hooverwood nursing home to assess compliance with regulatory requirements including medication administration, resident transfers, care practices, medication reviews, and food service.
Findings
The facility had multiple deficiencies including failure to complete self-medication administration assessments, failure to notify ombudsman and residents about transfers and bed hold policies, inadequate resident care including exposure and incontinence care, unsafe use of mechanical lifts, missing pharmacist monthly medication reviews, improper use of psychotropic medications, and failure to ensure meals were served at proper temperatures.
Deficiencies (8)
F 0554: The facility failed to ensure residents had self-medication administration assessments completed by the interdisciplinary team for 2 of 2 residents reviewed.
F 0623: The facility failed to ensure the ombudsman and resident or representative were notified in writing of the reason for transfer and discharge for 2 of 6 residents reviewed.
F 0625: The facility failed to notify residents or representatives in writing of the facility bed hold policy at the time of transfer or emergency transfer for 5 of 6 residents reviewed.
F 0677: The facility failed to ensure staff dressed a resident to avoid breast exposure and provide timely incontinence care for 1 of 1 dependent resident reviewed.
F 0689: The facility failed to ensure a dependent resident was evaluated prior to transfer with a sit-to-stand mechanical lift to ensure safe transfer for 1 of 3 residents reviewed for accident hazards.
F 0756: The facility failed to ensure residents' medications were reviewed monthly by the pharmacist for 3 of 5 residents reviewed for unnecessary medications.
F 0758: The facility failed to ensure PRN psychotropic medication was limited to 14 days and that Abnormal Involuntary Movement Scale assessments were completed for 2 of 5 residents reviewed for unnecessary medications.
F 0804: The facility failed to ensure a resident was alerted and awakened when her meal delivery occurred so the meal could be consumed at an appetizing temperature for 1 of 1 resident reviewed for room trays.
Report Facts
Residents reviewed for transfer and discharge: 6
Residents reviewed for medication: 5
Residents reviewed for self-medication: 2
Residents reviewed for accident hazards: 3
Minutes delay in food temperature check: 28
Food temperatures: 108.3
Food temperatures: 83
Food temperatures: 78.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 6 | LPN | Indicated no self-medication evaluation was seen for Residents 73 and 77 |
| Unit Manager 7 | Unit Manager | Indicated residents should have self-administration evaluations and described transfer evaluation process |
| Social Service Director | Social Service Director | Indicated facility did not notify ombudsman of hospitalizations |
| Director of Nursing | DON | Provided facility policies and indicated missing documentation for bed hold policy and medication reviews |
| Assistant Director of Nursing | ADON | Noted resident's breast exposure and missing AIMS assessments |
| Certified Nursing Assistant 8 | CNA | Indicated residents needed to be checked and changed every 2 hours or when needed; described transfer practices |
| Certified Nursing Assistant 9 | CNA | Assisted with incontinence care for Resident 28 |
| Unit Manager 10 | Unit Manager | Involved in transfer of Resident 28 with sit-to-stand lift |
| Executive Chef | Executive Chef | Checked food temperatures for Resident 34's breakfast tray |
| General Manager | General Manager | Present during food temperature check |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 162
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
Failed to ensure residents were treated with respect and dignity for 2 of 12 residents reviewed for resident rights.
Failed to ensure two staff members completed a Hoyer lift transfer to prevent an accident for 1 of 3 residents reviewed for accidents.
Failed to ensure a staff member followed the policy and procedure when administering narcotics to 2 of 7 residents reviewed for pharmaceutical services.
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
Deficiencies: 3
Date: Jan 22, 2025
Visit Reason
The inspection was conducted in response to multiple complaints regarding resident care concerns, including allegations of staff mistreatment, improper use of mechanical lifts, and medication administration errors.
Complaint Details
This citation relates to Complaints IN00446410, IN00446579, IN00450262, IN00449484, and IN00445292. The complaints involved allegations of resident mistreatment, improper mechanical lift transfers, and medication administration errors. The facility corrected the deficiencies prior to the survey.
Findings
The facility was found to have failed in ensuring residents were treated with dignity, properly assisted during mechanical lift transfers, and that narcotic medications were administered and documented correctly. Deficient practices were corrected prior to the survey start date, and involved staff terminations and staff in-service training.
Deficiencies (3)
F 0550: The facility failed to ensure residents were treated with respect and dignity for 2 of 12 residents reviewed. Two CNAs were terminated for mistreatment of residents. The deficient practice was corrected prior to the survey.
F 0689: The facility failed to ensure two staff members completed a Hoyer lift transfer with a second person for 1 of 3 residents reviewed for accidents. One CNA was terminated for transferring a resident without a second staff member. The deficient practice was corrected prior to the survey.
F 0755: The facility failed to ensure a staff member followed policy when administering narcotics to 2 of 7 residents reviewed. An agency nurse did not document narcotic administration properly and was placed on the do not return list. The deficient practice was corrected prior to the survey.
Report Facts
Residents reviewed for rights: 12
Residents reviewed for accidents: 3
Residents reviewed for pharmaceutical services: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in resident dignity and respect finding and terminated for mistreatment. |
| CNA 5 | Certified Nursing Assistant | Named in resident dignity and respect finding and terminated for mistreatment. |
| CNA 9 | Certified Nursing Assistant | Named in mechanical lift transfer deficiency and terminated for transferring resident without a second staff member. |
| RN 10 | Registered Nurse | Named in narcotic medication administration deficiency and placed on do not return list. |
Inspection Report
Complaint Investigation
Census: 165
Deficiencies: 1
Date: Dec 27, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00449779 regarding allegations of sexual abuse by a staff member.
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.
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.
Deficiencies (1)
Failure to protect resident from sexual abuse by a staff member.
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
Deficiencies: 1
Date: Dec 27, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging sexual abuse of a resident by a staff member.
Complaint Details
This citation relates to Complaint IN00449779. The complaint was substantiated as the facility failed to protect Resident B from sexual abuse by a housekeeping staff member.
Findings
The facility failed to protect a resident from sexual abuse by a contracted housekeeping staff member. Immediate jeopardy was identified but removed prior to the survey start after corrective actions were implemented.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including sexual abuse. A housekeeping employee was found lying on top of a resident with pants down and the resident's private area exposed.
Report Facts
Residents Affected: 1
Dates: Dec 21, 2024
Employee warnings: 2
15-minute checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 2 | Contracted Housekeeping Staff | Named in sexual abuse finding and terminated after the incident. |
| Housekeeping Supervisor | Observed and reported the abuse incident involving Housekeeper 2. | |
| Interim Executive Director | Interim Executive Director | Notified of immediate jeopardy and involved in corrective actions. |
| Interim Director of Nursing | Interim Director of Nursing | Notified of immediate jeopardy and involved in corrective actions. |
| LPN 4 | Licensed Practical Nurse | Assessed Resident B after the incident and provided statements. |
| RN 3 | Registered Nurse | Received report from Housekeeping Supervisor about the incident. |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 168
Deficiencies: 3
Date: Oct 11, 2024
Visit Reason
The visit was conducted for the investigation of complaints IN00442366, IN00443399, IN00443457, and IN00443672.
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.
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.
Deficiencies (3)
Facility failed to ensure a resident was free from physical abuse related to a staff member pulling a resident's ears causing redness.
Facility failed to ensure residents' personal property and credit card were kept safe and secure during admission for 2 residents.
Facility failed to ensure a resident's medication list was kept private during admission, resulting in a HIPAA breach.
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
Deficiencies: 3
Date: Oct 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse, misappropriation of property, and breach of resident privacy at the facility.
Complaint Details
The inspection relates to Complaint IN00443672 for abuse and Complaint IN00443457 for breach of resident privacy and misappropriation of property. The complaints were substantiated with corrective actions completed prior to the survey.
Findings
The facility was found to have failed in protecting residents from physical abuse, misappropriation of property, and maintaining resident-identifiable information privacy. Deficient practices were corrected prior to the survey, including termination of involved staff and staff education.
Deficiencies (3)
F 0600: The facility failed to ensure a resident was free from physical abuse when a staff member grabbed a resident with dementia by his ears and pulled him out of another resident's room. The staff member was terminated and the issue was corrected prior to the survey.
F 0602: The facility failed to protect residents' personal property and credit card during admission for 2 residents, resulting in theft and unauthorized credit card use. The involved staff member was terminated and corrective actions were implemented.
F 0842: The facility failed to safeguard resident-identifiable information when a resident's medication list was sent incorrectly to the hospital, causing a delay in medication administration. Staff were educated and corrective actions taken prior to the survey.
Report Facts
Residents reviewed for abuse: 4
Residents reviewed for misappropriation of property: 3
Residents reviewed for resident-identifiable information: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in physical abuse finding; terminated for abuse |
| CNA 2 | Certified Nursing Assistant | Witnessed abuse and reported to DON |
| LPN 4 | Licensed Practical Nurse | Assessed resident after abuse report |
| CNA 5 | Certified Nursing Assistant | Named in misappropriation of property finding; terminated for theft |
| LPN 8 | Licensed Practical Nurse | Involved in HIPAA breach; educated on proper procedures |
| LPN 9 | Licensed Practical Nurse | Involved in HIPAA breach; educated on proper procedures |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 145
Deficiencies: 0
Date: Jul 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438867.
Complaint Details
Complaint IN00438867 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 10
Medicaid residents: 96
Other residents: 39
Inspection Report
Re-Inspection
Census: 142
Capacity: 155
Deficiencies: 2
Date: 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.
Deficiencies (2)
HVAC heating, ventilation, and air conditioning shall comply with 9.2 and be installed in accordance with the manufacturer's specifications.
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.
Report Facts
Certified beds: 155
Census: 142
Inspection Report
Re-Inspection
Census: 147
Capacity: 155
Deficiencies: 8
Date: 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.
Deficiencies (8)
Failed to implement emergency power system inspection, testing, and maintenance requirements per NFPA 110 and Life Safety Code.
Failed to maintain fire alarm system in accordance with NFPA 72; semi-annual inspections not documented or incomplete.
Failed to ensure means of egress door was readily accessible without improper locking or signage.
Failed to ensure fire dampers were inspected and maintained every 4 years per NFPA 90A and NFPA 80.
Trash chute door failed to be self-closing and positively latching as required by NFPA 82.
Failed to maintain written records of weekly emergency generator inspections for 4 weeks of the most recent 52 week period.
Failed to exercise emergency generator monthly for 1 of 12 months as required by NFPA 110.
Building construction type not maintained for new construction in sprinkler riser room; hole in ceiling exposing underside of second floor decking.
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
Date: 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.
Complaint Details
Complaint IN00425592 was investigated and found to be corrected.
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.
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
Date: 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.
Deficiencies (12)
Failed to implement emergency power system inspection, testing, and maintenance requirements; missing weekly and monthly load testing documentation.
Failed to maintain fire alarm system in accordance with NFPA 72; missing semi-annual inspection documentation.
Failed to ensure 1 of 52 fire extinguishers was accessible at all times; extinguisher blocked by podium and stacked chairs.
Trash chute discharge room door lacked positive latching mechanism; door failed to latch properly.
Failed to conduct quarterly fire drills on all shifts and failed to document staff participation for one third shift fire drill.
Failed to ensure annual inspection and testing of all fire door assemblies; missing itemized listing and documentation.
Failed to ensure documentation of electrical outlet receptacle testing for all resident sleeping rooms was available for review.
Failed to ensure all fire dampers were inspected and maintained at least every four years; missing documentation and inspection date.
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.
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.
Sprinkler riser room closet missing an automatic sprinkler to ensure coverage.
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
Date: 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.
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.
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.
Deficiencies (12)
Failed to ensure a resident had a self-medication administration assessment and medications were not left unattended in a resident's room.
Failed to ensure PASARR Level II was recorded on the Minimum Data Set for residents with mental disorders.
Failed to develop and implement resident specific interventions to address communication limitations for a resident who spoke Russian.
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.
Failed to ensure ongoing program of cognitively stimulating activities for residents diagnosed with dementia.
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.
Failed to ensure residents received adequate supervision and interventions to prevent falls and failed to determine root cause or implement new interventions after falls.
Failed to label oxygen tubing and administer correct oxygen flow for residents receiving respiratory care.
Failed to ensure medications were stored according to pharmacy directions, labeled and dated, and schedule II medication cards were not compromised.
Failed to keep stored food items covered in cold storage room for safe and sanitary conditions.
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.
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: 11
Date: Mar 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to multiple concerns including medication administration, resident care, infection control, and safety.
Complaint Details
The inspection was complaint-driven, addressing multiple complaints including medication administration errors, inadequate resident care, infection control lapses, and safety concerns.
Findings
The facility was found deficient in multiple areas including failure to ensure proper medication administration and self-medication assessments, inadequate resident assessments for PASARR, failure to provide appropriate communication support for a non-English speaking resident, insufficient assistance with activities of daily living, lack of cognitively stimulating activities for residents with dementia, improper response to a choking incident, failure to maintain upright positioning for residents in wheelchairs, failure to notify physicians of abnormal blood sugars and missing weights, inadequate fall management interventions, improper oxygen therapy practices, medication storage issues, unsafe food storage, and lapses in infection prevention and control practices.
Deficiencies (11)
F 0554: The facility failed to ensure a resident had a self-medication administration assessment and medications were not left unattended in the resident's room.
F 0642: The facility failed to ensure a resident with a PASARR level II was recorded on the Minimum Data Set assessment.
F 0676: The facility failed to develop and implement resident specific interventions to address communication limitations for a resident who spoke only Russian.
F 0677: The facility failed to develop and implement resident specific interventions to ensure a cognitively impaired resident with a history of elder abuse received necessary grooming, bathing, and clothing care.
F 0679: The facility failed to ensure an ongoing program of cognitively stimulating activities for residents diagnosed with dementia.
F 0684: The facility failed to effectively administer back blows during a choking incident, maintain upright positioning for residents in chairs, notify physicians of abnormal blood sugars, and complete daily weights as ordered.
F 0689: The facility failed to determine the root cause and implement new interventions for falls for a resident with multiple falls.
F 0695: The facility failed to label oxygen tubing and administer correct oxygen flow rates as ordered for residents receiving oxygen therapy.
F 0761: The facility failed to ensure medications were stored according to pharmacy directions, were labeled and dated, and schedule II medication cards were not compromised.
F 0812: The facility failed to keep stored food items covered in the cold storage room.
F 0880: The facility failed to ensure infection control practices including hand hygiene, use of PPE, equipment disinfection, and proper catheter bag placement for residents on transmission based precautions.
Report Facts
Blood sugar level: 399
Blood sugar level: 385
Blood sugar level: 358
Missing daily weights: 48
Medication cards compromised: 10
Loose pills: 24
Residents reviewed for infection control: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 9 | Performed Heimlich maneuver during choking incident for Resident S | |
| ST 10 | Speech Therapist | Assisted with Heimlich maneuver and provided education on swallowing precautions for Resident S |
| UM 8 | Unit Manager | Observed Heimlich maneuver and reviewed care plan for Resident S |
| LPN 2 | Licensed Practical Nurse | Observed not performing hand hygiene and not disinfecting lift between residents |
| LPN 1 | Licensed Practical Nurse | Observed not disinfecting lift and not performing hand hygiene |
| ADNS | Assistant Director of Nursing Services | Provided interviews regarding fall management, infection control, and oxygen therapy policies |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 6, 2024
Visit Reason
The inspection was conducted in response to complaint IN00425592 concerning multiple care and safety issues at the facility.
Complaint Details
Complaint IN00425592 triggered the investigation into multiple care deficiencies including communication barriers, ADL assistance, activity programming, emergency response, resident positioning, clinical monitoring, fall management, and infection control.
Findings
The facility failed to provide adequate communication support for a non-English speaking resident, failed to ensure proper assistance with activities of daily living for cognitively impaired residents, lacked an ongoing program of cognitively stimulating activities for residents with dementia, failed to properly administer emergency choking procedures, did not maintain proper resident positioning, failed to notify physicians of abnormal blood sugar levels and missing weights, did not implement new interventions after falls, and failed to maintain proper infection control practices including PPE use and equipment disinfection.
Deficiencies (6)
F 0676: The facility failed to develop and implement resident-specific interventions to address communication limitations for a Russian-speaking resident, including failure to use translation services.
F 0677: The facility failed to ensure a cognitively impaired resident with a history of elder abuse received necessary grooming, bathing, and clothing assistance.
F 0679: The facility failed to provide an ongoing program of cognitively stimulating activities for residents diagnosed with dementia, with multiple days lacking documented activity participation.
F 0684: The facility failed to properly administer back blows during a choking emergency, failed to revise the care plan with swallowing concerns, failed to ensure upright positioning for residents in chairs, failed to notify physicians of abnormal blood sugars and missing weights, and failed to provide proper food preparation and supervision.
F 0689: The facility failed to determine root causes and implement new interventions for falls for a resident with multiple falls and weakness.
F 0880: The facility failed to ensure infection control practices including proper use of PPE, hand hygiene, equipment disinfection, and prevention of contamination of urinary catheter bags for residents on transmission-based precautions.
Report Facts
Missing daily weights: 46
Blood sugar levels above call parameters: 3
Residents reviewed for infection control: 7
Residents affected by deficiencies: 4
Residents reviewed for activities: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 9 | Certified Nursing Assistant | Named in the choking emergency response for Resident S. |
| ST 10 | Speech Therapist | Involved in choking emergency response and care planning for Resident S. |
| UM 8 | Unit Manager | Observed and described choking emergency response and care plan issues for Resident S. |
| LPN 2 | Licensed Practical Nurse | Observed failing to perform hand hygiene and disinfect equipment during resident care. |
| LPN 1 | Licensed Practical Nurse | Observed failing to disinfect equipment and perform hand hygiene. |
| ADNS | Assistant Director of Nursing Services | Provided interviews regarding fall management, infection control policies, and resident care. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00419026 completed on October 12, 2023.
Complaint Details
Investigation of Complaint IN00419026 was completed with findings of compliance.
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.
Report Facts
Complaint Investigation ID: 419026
Inspection Report
Complaint Investigation
Census: 149
Capacity: 149
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00419026 regarding medication administration errors and labeling deficiencies.
Complaint Details
Complaint IN00419026 - Federal/State deficiencies related to the allegations are cited at F760 and R301.
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.
Deficiencies (2)
Failed to ensure residents were free of significant medication errors for 3 of 6 residents reviewed for medication administration (Residents B, C, and 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
Deficiencies: 1
Date: Oct 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration errors at the facility.
Complaint Details
This Federal Tag relates to Complaint IN00419026.
Findings
The facility failed to ensure residents were free from significant medication errors for 3 of 6 residents reviewed. Errors included administration of wrong insulin, medication given despite hold orders, and improper application of fentanyl patches.
Deficiencies (1)
F 0760: The facility failed to ensure residents were free from significant medication errors for 3 of 6 residents reviewed. Errors included administering the wrong insulin to Resident B, giving Xeloda medication to Resident C despite hold orders, and improper application of fentanyl patches to Resident D.
Report Facts
Residents reviewed for medication administration: 6
Residents affected: 3
Medication administration errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Administered wrong insulin to Resident B |
| Director of Nursing | Provided education documents and interviews regarding medication errors | |
| LPN 2 | Licensed Practical Nurse | Applied second fentanyl patch to Resident B and was educated after error |
| LPN 1 | Licensed Practical Nurse | Interviewed about medication administration procedures |
| Assistant Director of Nursing | Signed education form related to Xeloda medication orders |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 147
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00415471 and IN00415220.
Complaint Details
Complaint IN00415471 and Complaint IN00415220 were investigated with no deficiencies cited related to the allegations.
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.
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
Date: 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
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
The inspection was conducted due to a complaint regarding a resident injury during transfer where proper transfer protocols were allegedly not followed.
Complaint Details
The complaint investigation found that Resident 2 was transferred improperly by a CNA alone without a gait belt, contrary to care plan and assignment sheet instructions. The fall caused a fracture requiring surgery. The CNA was aware of the proper procedure but did not follow it due to being in a hurry.
Findings
The facility failed to protect Resident 2 from injury during a transfer when a CNA did not follow transfer instructions requiring two staff and a gait belt. Resident 2 sustained a femur fracture and required hospitalization and surgery.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. A CNA transferred Resident 2 alone without a gait belt, resulting in a fall and femur fracture.
Report Facts
Residents affected: 3
Gait belts in resident room: 3
Date of fall: Jun 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in transfer incident and interview regarding improper transfer |
| LPN 2 | Licensed Practical Nurse | Assessed Resident 2 after fall and assisted with transfer to bed |
| TX 3 | Therapy Staff | Provided assessment on transfer requirements for Resident 2 |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 145
Deficiencies: 1
Date: 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.
Complaint Details
Complaint IN00412984 and Complaint IN00412833 were investigated. No deficiencies related to the allegations of either complaint were 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.
Deficiencies (1)
Failure to protect Resident 2 from injury during transfer when CNA did not follow transfer instructions, resulting in a femur fracture.
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
Date: 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
Date: 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.
Deficiencies (6)
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.
Fire alarm system was in trouble mode for at least a couple months due to control board and battery charging issues; repairs pending.
Failed to maintain fire alarm system in accordance with NFPA 70 and NFPA 72 standards.
Failed to ensure emergency generator exercised monthly and annually per NFPA 110 standards.
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.
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
Date: 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.
Complaint Details
Complaint IN00385997 and Complaint IN00394199 were investigated and found to be corrected.
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.
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
Date: 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.
Deficiencies (11)
Failure to implement emergency power system inspection, testing, and maintenance requirements per NFPA 110 and Life Safety Code.
Failure to ensure annual inspection and testing of all fire door assemblies in accordance with LSC 19.1.1.4.1.1.
Failure to maintain means of egress free of obstructions; a plastic chest of drawers was stored in a corridor.
Failure to ensure door locking arrangements comply with clinical needs or security threat locking requirements; exit door code not posted.
Failure to ensure fire damper inspections and maintenance at least every four years per NFPA 90A and NFPA 80.
Failure to maintain monthly testing documentation of elevator firefighter recall as required by ASME A17.1/CSA B44.
Emergency generator remote annunciator panel not in proper operating condition; 'Low Coolant Temp' trouble light illuminated.
Failure to maintain weekly emergency generator inspection documentation for 28 weeks of the most recent 52 week period.
Failure to document monthly load testing for six months and annual load bank testing for emergency generator as required by NFPA 110.
Failure to document 36 month period emergency generator testing for four continuous hours as required by NFPA 110.
Use of power strips in patient care vicinity as substitute for fixed wiring; CPAP and oxygen concentrator plugged into lamp stand receptacles.
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
Complaint Investigation
Deficiencies: 14
Date: Dec 21, 2022
Visit Reason
Complaint investigations related to medication notification failures, care plan deficiencies, ADL assistance, wound care, catheter care, infection control, medication storage, and other regulatory compliance issues.
Complaint Details
Complaint investigations IN00394199, IN00385997 and others related to medication notification failures, care plan deficiencies, ADL assistance, wound care, catheter care, infection control, medication storage, and food safety.
Findings
The facility failed to notify physicians and family of medication non-administration, develop comprehensive care plans, provide adequate ADL assistance, follow physician orders for medications and catheter care, maintain infection control precautions, properly store medications and chemicals, and ensure safe food handling and respiratory care.
Deficiencies (14)
F 0580: The facility failed to notify the physician and responsible party when Tacrolimus medication was not given for Resident 21.
F 0656: The facility failed to develop and implement a comprehensive care plan specific to Resident 50's osteogenesis imperfecta diagnosis.
F 0677: The facility failed to provide assistance with activities of daily living, specifically nail care, for Resident 21.
F 0684: The facility failed to provide appropriate treatment and care according to orders for Residents 21 and 9, including missed Tacrolimus doses and lack of bowel protocol implementation.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers, including incorrect use of Dakin's solution for Residents 299, 21, and 112.
F 0689: The facility failed to ensure kitchenettes cleaning chemicals were locked and secured away in a cabinet on Unit 2B.
F 0690: The facility failed to provide appropriate catheter care for Residents 21 and 86, including failure to change catheters per orders and failure to address catheter tubing sediment and odor.
F 0695: The facility failed to ensure oxygen tubing was changed weekly and failed to ensure Resident 48 received oxygen at the correct liter flow per physician order.
F 0757: The facility failed to ensure Resident 120's blood sugar was checked and insulin administered per orders and failed to ensure pain was assessed by a licensed nurse prior to QMA administering pain medication.
F 0758: The facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication for Resident 50.
F 0761: The facility failed to ensure oral medications were stored separately from eye and ear medications, failed to store medications in packaging, and failed to label medications with open dates in 3 medication carts.
F 0812: The facility failed to properly handle and store potentially hazardous foods, maintain kitchen equipment and areas to prevent microbial growth and cross contamination, and label and date refrigerated products in the main kitchen and 2 kitchenettes.
F 0880: The facility failed to follow CDC guidelines to prevent transmission of MRSA, failed to implement infection control practices during meal service for a resident with active cough and Influenza A, and failed to properly disinfect blood spills in resident rooms.
F 0883: The facility failed to ensure Resident 303 received pneumococcal immunization after consent was obtained.
Report Facts
Missed Tacrolimus doses: 9
Pressure ulcer measurements: 1.4
Pressure ulcer measurements: 0.9
Oxygen liters: 3
Insulin units: 5
Medication carts with storage issues: 3
Kitchenette mold and damage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 15 | Licensed Practical Nurse | Performed wound care and indicated Resident 21's fingernails were long. |
| Assistant Director of Nursing | ADON | Interviewed multiple times regarding medication notification, catheter care, and infection control. |
| Consulting Pharmacist | Indicated communication errors related to medication billing and appropriateness of antipsychotic use. | |
| Nurse Practitioner | Notified about catheter concerns and medication issues for Resident 21. | |
| QMA 10 | Qualified Medication Aide | Administered pain medication without nurse assessment. |
| LPN 12 | Licensed Practical Nurse | Observed oxygen and infection control issues. |
| LPN 13 | Licensed Practical Nurse | Observed medication storage and blood on floor issues. |
| Corporate Chef | Interviewed regarding kitchen and food safety concerns. | |
| Registered Dietitian | Observed kitchen cleanliness and food storage issues. | |
| Nurse Educator | Interviewed regarding catheter care and blood spill cleanup. | |
| Director of Nursing | DON | Interviewed regarding catheter care and medication issues. |
| Infection Preventionist | Interviewed regarding infection control and vaccination issues. |
Inspection Report
Routine
Census: 160
Deficiencies: 15
Date: Dec 12, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of complaints IN00394199, IN00382714, and IN00385997.
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.
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.
Deficiencies (15)
Failed to notify physician and responsible party when Tacrolimus medication was not given or available for Resident 21.
Failed to develop and implement a comprehensive care plan for Resident 50 with osteogenesis imperfecta.
Failed to provide assistance with ADLs related to nail care for Resident 21.
Failed to provide necessary care and services for Resident 21 and Resident 9 related to medication administration and bowel protocol.
Failed to ensure pressure ulcer care and treatment consistent with professional standards for Residents 299, 21, and 112.
Failed to ensure kitchenettes cleaning chemicals were locked and secured away in a cabinet (Unit 2B).
Failed to ensure residents with indwelling catheters received appropriate catheter care and timely catheter changes for Residents 21 and 86.
Failed to ensure oxygen tubing was changed weekly and residents received oxygen at the correct ordered liter flow for Residents 24 and 48.
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.
Failed to ensure psychotropic medication for Resident 50 had an appropriate diagnosis and was monitored for side effects.
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.
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.
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.
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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