Inspection Reports for
Hubbard Hill Estates Inc
28070 CR 24, ELKHART, IN, 46517
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
100% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 14, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Hubbard Hill Estates Inc.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Date: Mar 14, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450298.
Complaint Details
Complaint IN00450298 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: 15
Medicaid residents: 14
Other residents: 31
Inspection Report
Census: 61
Capacity: 66
Deficiencies: 0
Date: Sep 30, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as with Life Safety Code requirements including fire safety and building construction standards.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 10, 2024
Visit Reason
The inspection was conducted based on complaints regarding residents' access to personal funds and the proper storage of oxygen accessories.
Complaint Details
The investigation was complaint-driven, focusing on residents' rights to access personal funds and safe respiratory care. The findings substantiated issues with access to funds and oxygen equipment storage.
Findings
The facility failed to ensure a resident could withdraw money from her personal funds on weekends and evenings. Additionally, the facility failed to provide proper storage of oxygen accessories for a resident using oxygen therapy.
Deficiencies (2)
F 0567: The facility failed to ensure a resident was able to withdraw her money on weekends and evenings. Resident 31 reported inability to access funds outside business hours despite policy stating reasonable access should be provided.
F 0695: The facility failed to provide proper storage of oxygen accessories for a resident. Resident 11's nasal cannula tubing was observed wrapped around the bedrail, on the floor, and draped over a recliner arm.
Report Facts
Residents reviewed for personal funds: 1
Residents reviewed for oxygen: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business office manager | Provided information about residents' access to personal funds. | |
| Administrator | Provided policy and statements regarding residents' access to funds. | |
| CNA 8 | Indicated proper storage of nasal cannula tubing. | |
| Director of Nursing | Provided oxygen use policy. |
Inspection Report
Annual Inspection
Census: 163
Capacity: 163
Deficiencies: 2
Date: Sep 10, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted on September 4, 5, 6, 9, and 10, 2024.
Findings
The facility was found to have deficiencies related to resident access to personal funds outside business hours and improper storage of oxygen tubing for residents on oxygen therapy. Corrective actions and policy updates were implemented to address these issues.
Deficiencies (2)
Facility failed to ensure a resident was able to withdraw her money on weekends and evenings for 1 of 1 resident reviewed for personal funds (Resident 31).
Facility failed to provide proper storage of oxygen accessories for 1 of 3 residents reviewed for oxygen (Resident 11).
Report Facts
Census Bed Type Total: 163
SNF/NF Census: 16
SNF Census: 43
Residential Census: 104
Census Payor Type Total: 59
Medicare Census: 15
Medicaid Census: 16
Other Payor Census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Knouse | LNHA | Signed as Laboratory Director or Provider/Supplier Representative |
| Business office manager | Interviewed regarding resident access to personal funds | |
| Administrator | Interviewed regarding resident access to personal funds and facility policy | |
| CNA 8 | Interviewed regarding oxygen tubing storage | |
| Director of Nursing | Provided oxygen use policy |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure Survey.
Findings
Hubbard Hill Estates Inc was found to be in compliance with 42 CFR Part 483, Subpart B and 10 IAC 16.2-3.1 based on the paper compliance review.
Inspection Report
Complaint Investigation
Census: 59
Capacity: 197
Deficiencies: 0
Date: Mar 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429709.
Complaint Details
Complaint IN00429709 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00429709 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 59
Total Capacity: 197
Census Bed Type: 46
Census Bed Type: 13
Census Bed Type: 138
Census Payor Type: 13
Census Payor Type: 14
Census Payor Type: 32
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 0
Date: Dec 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422881.
Complaint Details
Complaint IN00422881 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420293.
Complaint Details
Complaint IN00420293 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 61
Census Bed Type - SNF: 48
Census Bed Type - SNF/NF: 13
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 13
Census Payor Type - Other: 32
Inspection Report
Life Safety
Census: 58
Capacity: 66
Deficiencies: 1
Date: Oct 12, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and in substantial compliance with Life Safety Code requirements. However, a deficiency was cited for failure to maintain a spare sprinkler cabinet large enough to fit all spare sprinkler heads and a sprinkler wrench on the premises, which could affect all residents and staff.
Deficiencies (1)
Failed to ensure 2 of 2 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet large enough to fit all spare sprinkler heads, and a sprinkler wrench on the premises.
Report Facts
Certified beds: 66
Census: 58
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terry Schollmeier | LNHA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Deficiencies: 2
Date: Sep 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning and infection prevention and control practices at the nursing home.
Findings
The facility failed to develop and implement a complete care plan for a resident's skin issue and failed to ensure proper infection control practices during blood glucose monitoring and insulin administration.
Deficiencies (2)
F 0656: The facility failed to have a care plan for a skin issue for 1 of 3 residents reviewed for skin. Resident 18 had a scabbed wound on the right 2nd toe with physician orders but no care plan was documented.
F 0880: The facility failed to ensure proper infection control practices related to fanning dry skin after alcohol cleansing and not wearing gloves during insulin injection for 1 of 1 observed instances (RN 4).
Report Facts
Residents reviewed for skin issue: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Named in infection control findings for improper glove use and fanning skin dry | |
| Director of Nursing | Provided policies and interviews related to care plan and infection control | |
| Infection Preventionist | Interviewed regarding care plan requirements |
Inspection Report
Renewal
Census: 131
Capacity: 191
Deficiencies: 2
Date: Sep 13, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and the Investigation of Complaint IN00413253.
Complaint Details
Complaint IN00413253 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies related to care planning for a resident's skin issue and infection prevention and control practices during medication administration. The complaint investigation found no deficiencies related to the allegations. The facility was found to be in compliance with State Residential Licensure Survey requirements.
Deficiencies (2)
Failed to have a care plan for a skin issue for 1 of 3 residents reviewed for skin (Resident 18).
Failed to ensure proper infection control practices related to fanning dry skin after cleansing with alcohol and not wearing gloves during insulin injection (RN 4).
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 12
Census Bed Type - SNF: 48
Census Bed Type - Residential: 131
Total Capacity: 191
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 12
Census Payor Type - Other: 31
Total Census Payor: 60
Resident 18 skin issue measurement: 1.2
Resident 18 skin issue measurement: 2
Medication dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Named in infection control deficiency related to medication administration and blood glucose monitoring |
| Director of Nursing | Provided policies and interviews related to care plan and infection control deficiencies | |
| Infection Preventionist | Interviewed regarding care plan deficiency for Resident 18 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on September 13, 2023.
Findings
Hubbard Hill Estates Inc was found to be in compliance with 42 CFR Part 483, Subpart B and 10 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 1
Date: Dec 21, 2022
Visit Reason
This visit was conducted for the investigation of complaint IN00397056, which was substantiated with related state deficiencies cited.
Complaint Details
Complaint IN00397056 was substantiated with state deficiencies related to the allegations cited at R0027.
Findings
The facility failed to ensure resident rights for residents in one of four households in the Living Wisdom Center Memory Care (Tudor). The entire Tudor unit was placed under quarantine due to one resident testing positive for COVID-19, and residents were denied leaves of absence even if they tested negative.
Deficiencies (1)
Failure to ensure resident rights for residents in the Living Wisdom Center Memory Care (Tudor) unit related to quarantine and leave of absence restrictions.
Report Facts
Residential Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terry L Schollmeier | COO/LNHA | Signed the report |
| Living Wisdom Memory Care Program Director | Interviewed regarding quarantine practices and resident restrictions | |
| Director of Nursing | Interviewed regarding quarantine practices and resident restrictions | |
| Administrator | Interviewed regarding quarantine practices and resident restrictions |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Date: Nov 9, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00388605.
Complaint Details
Complaint IN00388605 was substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00388605 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Life Safety
Census: 58
Capacity: 66
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, and with Life Safety Code requirements including fire safety and sprinkler systems. The facility has a capacity of 66 beds and a census of 58 at the time of the survey.
Report Facts
Certified beds: 66
Census: 58
Generator capacity: 400
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 27, 2022
Visit Reason
The inspection was conducted based on complaints regarding catheter care and food preparation practices at the facility.
Complaint Details
The visit was complaint-related, focusing on catheter care and food sanitation issues. The catheter care deficiency affected one resident, and the food sanitation deficiency potentially affected all 61 residents. The catheter care issue was substantiated based on observations and interviews.
Findings
The facility failed to provide appropriate catheter care for one resident, including improper handling and uncovered catheter drainage tubing. Additionally, the facility failed to ensure food was prepared and served in a sanitary manner in both the main and healthcare kitchens, potentially affecting all residents.
Deficiencies (2)
F 0690: The facility failed to provide appropriate catheter care and ensure the catheter drainage tubing tip was covered for 1 of 1 residents reviewed for catheter use. Observations showed catheter tubing dragging on the floor and uncovered drainage bag tip.
F 0812: The facility failed to ensure food was prepared and served in a sanitary manner in both the main and healthcare kitchens. Observations included dirty ovens, contaminated food scoops, and improper glove use by kitchen staff.
Report Facts
Residents affected by catheter care deficiency: 1
Residents potentially affected by food sanitation deficiency: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Observed providing catheter care and interviewed regarding glove use |
| Director of Nursing | Interviewed regarding catheter tubing coverage policy | |
| Unit Manager 6 | Provided catheter care and urinary leg drainage bag policies | |
| Food Service Supervisor | Interviewed regarding kitchen sanitation and cleaning schedules | |
| Employee 7 | Assistant Food Service Supervisor | Interviewed regarding food handling review with cook |
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