Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hooverwood during CMS and state inspections, most recent first.
MDS assessments were inaccurately coded for multiple residents. Several residents with documented falls, injuries, ER transfers, or hospitalization were marked as having no falls with injury or major injury on their MDSs, while one resident was incorrectly coded as having a tracheostomy despite no supporting clinical record, orders, or care plan. The MDS coordinator acknowledged the coding errors during interview.
The facility failed to follow physician orders for daily weights and medication hold parameters for several residents. A resident with CHF missed ordered daily weights, another resident had significant weight gains without physician notification, and a resident with BP-related PRN orders had multiple missed administrations when BP was outside ordered parameters. Another resident received metoprolol multiple times despite diastolic BP readings below the hold limit, even though staff interviews and facility policy stated orders with parameters should be checked before administration.
Call Light Not Kept Within Reach: A resident with Parkinson's disease, a T3/T4 vertebral dislocation, and a history of falls was observed with the call light out of reach while sitting in a Broda chair and again while lying in bed. The care plan directed staff to keep the call light within reach, and CAN, CNA, and DON interviews confirmed it should have been reachable.
Medications in 3 of 5 reviewed med carts were not labeled with open dates. An opened bottle of loperamide had another resident's name label on it and no open date, an opened bottle of alendronate had no open date, an opened bottle of liquid morphine had no open date, and an opened bottle of probiotic had no open date. An LPN, an RN, and the DON all stated opened medications should be labeled when opened.
A resident with dementia and a history of wandering exited a secured unit unsupervised by passing through an unlocked stairway and an unlocked, alarmed exit door. Staff reset the alarm without investigating, and the resident was later found outside the facility by a CNA. The care plan and elopement policy did not include updated interventions or clear staff response procedures for door alarms, contributing to the resident's unsupervised exit.
A resident who was fully dependent on staff for toileting and hygiene was left without incontinence care for an entire shift. The resident was found sitting in a recliner with saturated clothing and furniture, and no care or documentation was provided by the assigned CNA during the shift, despite facility policies requiring regular checks and assistance.
A nurse repeatedly signed out and documented the administration of Norco, a narcotic pain medication, for a resident who did not actually receive the medication during daytime hours. The resident, who was alert and cognitively intact, reported only taking the medication at night, and the MAR did not show daytime administrations. Facility policies required proper documentation and narcotic counts, but these were not followed, resulting in the misappropriation of the resident's medication.
Two residents were found with medications at their bedside without required self-administration assessments by the IDT, as confirmed by an LPN and Unit Manager. Both residents had multiple diagnoses, and facility policy mandates such evaluations before allowing self-administration of medications.
A resident with severe cognitive impairment was repeatedly observed with her breast exposed in a public area, and on another occasion, was left in soiled incontinence briefs for an extended period, resulting in discomfort and odor. Nursing leadership and staff acknowledged the need for closer monitoring and adherence to policies requiring regular checks and prompt hygiene care.
A dependent resident with severe cognitive impairment and blindness was transferred using a sit-to-stand mechanical lift without a prior safety evaluation, despite her inability to participate in the transfer as required. Staff used the lift contrary to the care plan and facility policy, and the resident did not hold the handlebars, resulting in an unsafe transfer that required physical assistance to complete.
The facility did not ensure that a licensed pharmacist completed required monthly drug regimen reviews for several residents receiving psychoactive medications, resulting in missing documentation for multiple months. The DON confirmed that pharmacy reviews were not available for certain periods, particularly during a change in pharmacy providers, despite facility policy requiring regular review.
A resident who required set-up assistance for meals was repeatedly left asleep with meal trays delivered to her room, resulting in food cooling to unsafe and unappetizing temperatures. Despite the resident's stated preference to be awakened for meals, staff did not consistently do so, and her care plan lacked documentation of her meal delivery preferences. Food temperature checks confirmed that meals were served below required standards, and other residents also reported receiving cold food in their rooms.
Two residents reported being treated without respect and dignity by CNAs. One resident felt hurt by a CNA's rough and grouchy behavior, while another resident reported being yelled at and scolded by a different CNA. Both residents had significant medical histories and were unable to be interviewed during the survey.
A resident with multiple health conditions fell during a Hoyer lift transfer when a CNA attempted the procedure alone, contrary to facility policy requiring two staff members. The resident moved her hands, slid out of the lift, and was repositioned onto the floor, resulting in pain and the need for medication.
A facility failed to properly administer and document narcotic medications for two residents. An agency nurse, RN 10, did not document the administration of prescribed narcotics in the EMAR, despite signing them out on the narcotic sheet. Resident C's and Resident D's records showed discrepancies, with Resident D reporting only receiving Tylenol instead of Oxycodone. Resident H also had missing documentation for Oxycodone. The facility's policy required accurate documentation, which was not followed, leading to a deficiency in pharmaceutical services.
A resident with severe cognitive impairment was sexually assaulted by a contracted housekeeper in the dementia unit. The housekeeper was found on top of the resident with his pants down, while the resident's gown and brief were open. The resident, who required maximum assistance with personal care and had a self-care performance deficit, was unable to communicate effectively due to her condition and language barrier. The incident highlighted a failure in the facility's protective measures.
A resident with dementia was physically abused by a staff member who pulled the resident by the ears, causing redness. The incident was witnessed by another staff member who reported it to the DON. The resident's medical history included dementia and other conditions. The facility's policy on abuse was violated.
The facility failed to protect the personal property and financial assets of two residents. One resident's AirPods were stolen and pinged to a CNA's address, leading to her termination. Another resident's credit card was used without permission for a restaurant purchase, despite her inability to leave the facility independently. These incidents highlight lapses in securing residents' belongings and preventing unauthorized access by staff.
A privacy breach occurred when a resident's medication list was incorrectly sent to a hospital, leading to a delay in medication administration. Two LPNs were involved in preparing the resident for transfer, and an error was made when the medication list for another resident was included in the envelope. The mistake was discovered by the resident's niece, who reported it to the hospital staff, prompting the facility to send the correct information.
MDS Assessments Were Inaccurately Coded for Falls and a Tracheostomy
Penalty
Summary
The facility failed to ensure MDS assessments were accurately coded for 5 of 7 residents reviewed for resident assessments. Resident 6 had a fall in her room on 3/27/26, sustained a hematoma to her forehead, and was sent to the emergency room, but the 3/29/26 MDS indicated no falls with injury since admission. Resident 22 had a fall on 2/24/26 with a head laceration, emergency room evaluation, and 12 staples to the head, but the 3/12/26 MDS indicated no falls with major injuries. Resident 46 was hospitalized on 3/14/26 after a fall that resulted in a right femoral neck fracture, yet the 3/23/26 and 4/16/26 MDS assessments indicated no falls with major injury since admission. Resident 105 had a fall on 1/9/26 with a left hip hematoma and emergency room transfer, but the 1/28/26 MDS indicated no falls with injuries. Resident 8’s 3/25/26 MDS indicated the resident had a tracheostomy, although the clinical record did not show a tracheostomy, physician orders, or a care plan for one. During interview, the MDS coordinator stated Resident 6 should have been marked for a fall with injury, Resident 22 had a fall with injury that should have been marked, Resident 46’s fall with injury should have been on the March MDS, and Resident 105 was not marked for falls. The MDS coordinator also stated Resident 8 was incorrectly marked as having a tracheostomy and that the assessment was modified, while the original MDS completion date remained the same.
Failure to Follow Orders for Weights and Medication Parameters
Penalty
Summary
The facility failed to follow physician orders for daily weights and medication administration for residents with congestive heart failure, blood pressure instability, and other chronic conditions. Resident 130 had CHF and a physician order to obtain a daily weight and notify the physician for a gain of more than 3 pounds in 24 hours or more than 5 pounds in 1 week, but the MAR showed daily weights were not obtained on 2/14/26 and 3/17/26. Resident 16 also had CHF and an order for daily weights with notification parameters, and the MAR showed a 6.2-pound weight increase on 2/28/26 and an 11.2-pound increase on 3/7/26, with no documentation that the physician was notified of either weight gain. Resident 108 had orders for PRN midodrine when systolic BP was less than 130 and PRN amlodipine when systolic BP was greater than 160, with instructions to check BP before meals and not administer after 6 p.m. The MAR showed multiple instances where midodrine was not administered when systolic BP was below 130 and multiple instances where amlodipine was not administered when systolic BP was above 160. The MAR for March 2026 also showed 13 times when systolic BP was less than 130 and midodrine was not given, and 2 times when systolic BP was greater than 160 and amlodipine was not given. Resident 14 had orders for metoprolol twice daily with hold parameters for systolic BP less than 100, diastolic BP less than 60, and heart rate less than 60. The MAR showed metoprolol was administered on multiple occasions when the diastolic BP was below 60, including several dates in April, as well as seven times in February and four times in March. Interviews with the DON, an LPN, and an RN indicated that medications with hold parameters should be checked against vital signs before administration and held when parameters were not met. The facility policy stated nursing shall follow physician orders as written and check parameters before administering medications.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a call light was within reach for Resident 11, who was reviewed for accommodation of needs. Resident 11 had diagnoses including Parkinson's disease, dislocation of the T3/T4 thoracic vertebra, and a history of falling. During an observation on 4/15/26 at 9:45 a.m., the resident was sitting in a Broda chair with the call light coiled on the nightstand out of reach. During another observation on 4/17/26, the resident was lying in bed with the call light on the ground under the bed. The care plan dated 7/8/24 identified the resident as at risk for falls and directed staff to keep the call light within reach and provide a safe environment with a reachable call light. During interviews, CAN 10, the DON, and CNA 9 each indicated the call light should be within the resident's reach when in bed or in a chair.
Medications Not Labeled With Open Dates
Penalty
Summary
The facility failed to ensure medications and biologicals were labeled in accordance with accepted professional principles because opened medications in 3 of 5 medication carts reviewed did not have open dates. During an observation on 4/17/26 with an LPN, the 1B [NAME] medication cart contained an opened bottle of loperamide hydrochloride 2 mg that was not labeled with an open date and also had another resident's name label on the bottle, as well as an opened bottle of alendronate 70 mg that was not labeled with an open date. The LPN stated the other resident's label should not have been on the medication and that the medication should have been labeled with an open date. During an observation on 4/20/26 with an LPN, the 2B East medication cart contained an opened bottle of liquid morphine 20 mg/ml that was not labeled with an open date, and the LPN stated it should have had an open date. During another observation on 4/20/26 with an RN, the 1A East medication cart contained an opened bottle of probiotic (Lactobacillus) that was not labeled with an open date. The RN stated that when a new bottle of medication is opened, the nurse should label it with the date and time it was opened. The DON also stated medications should be labeled with an open date at the time they are opened. The facility policy titled Medication Labeling, dated 5/2022, stated medications are to be labeled in compliance with State and Federal laws and maintained accurately labeled for safe and effective medication administration.
Failure to Prevent Elopement of Resident with Dementia and Wandering Behaviors
Penalty
Summary
A resident with dementia, severe cognitive impairment, and a known history of wandering and exit-seeking behaviors exited the facility unsupervised despite being on a secured locked unit and wearing a wanderguard device. The resident was able to leave the secured unit through an unlocked stairway door, descend to the first floor, and exit the building through an unlocked but alarmed door. The stairway door was supposed to be locked and checked daily by the Maintenance Director, but it was not checked on the day of the incident. The exit door alarm sounded, but staff reset the alarm without investigating the cause or checking outside, and the resident was not immediately located. The resident wandered approximately 0.4 miles away from the facility, crossing a two-lane road before being found by a CNA walking in the grass along the road. The resident's care plan and assessments documented her high risk for elopement, use of a wanderguard, and previous incidents of exit-seeking, including a prior event where she left the building and required intervention. Despite these documented risks and behaviors, there were no updated interventions in the care plan after the previous elopement incident, and the facility's elopement policy did not specify staff response to door alarms. Interviews and record reviews revealed that staff were not aware of the resident's exit until a code for a missing resident was called, and the alarmed door had been tampered with, preventing it from locking properly. Staff responding to the alarm did not open the door or check the area outside, and only later realized the resident was missing. The resident was eventually found without injury, but the incident demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision and monitoring were provided to prevent accidents for residents at risk of elopement.
Failure to Provide Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A dependent resident with a history of cerebral infarction, dementia, and type 2 diabetes mellitus was not provided incontinence care during an entire eight-hour shift. The resident was totally dependent on staff for toileting and hygiene, requiring a stand lift and assistance from two staff members. According to the care plan, peri-care was to be completed with each incontinence episode. However, documentation and interviews revealed that the assigned CNA did not provide or document any toileting or incontinence care for the resident during the shift. When the resident's daughter visited, she found the resident sitting in a recliner with a strong odor of urine and feces, and both the resident's clothing and recliner were saturated. The incontinence brief was so saturated it fell to the resident's knees when she was assisted to stand. The facility's point of care documentation confirmed that no toileting or incontinence care was recorded for the resident during the CNA's shift. The CNA later admitted to neglecting her duties during this period. The facility's policies and the CNA's job description required regular checks, assistance with toileting and incontinence needs, and proper documentation of care provided. These requirements were not met, resulting in the resident being left in soiled clothing and furniture for an extended period.
Misappropriation of Resident's Narcotic Medication by Staff
Penalty
Summary
A deficiency occurred when a nurse (RN) repeatedly signed out and documented the administration of Norco, a narcotic pain medication, for a resident who did not actually receive the medication. The resident, who was cognitively intact, alert, oriented, and a retired RN, consistently reported that she only took Norco at night to help her sleep and never during the day. Despite this, the narcotic count sheets showed that the RN signed out Norco for the resident on multiple occasions during daytime hours, often one tablet at a time, while the resident's order was for two tablets every six hours as needed for pain. The Medication Administration Record (MAR) did not reflect these daytime administrations, and the resident confirmed she had not received the medication during those times. Interviews with staff, including the DON and other nurses, confirmed that the facility's policy required all administered medications, especially PRN narcotics, to be documented both on the narcotic sheet and in the electronic MAR. If a medication was not documented in the MAR, it was considered not administered. The discrepancy was identified when another nurse noticed inconsistencies between the narcotic count sheet, the resident's order, and the MAR. The resident was able to identify her medications and was aware of what she had taken, further supporting that the narcotics were not administered as documented by the RN. The facility's policies also required a narcotic count at each shift change, with both off-going and on-coming nurses signing the count sheet. Despite these procedures, the RN continued to sign out and document the removal of Norco without actual administration to the resident, resulting in the misappropriation of the resident's medication. The resident's rights policy specifically stated that residents have the right to be free from misappropriation of property, which was not upheld in this instance.
Failure to Complete Self-Administration Medication Assessments
Penalty
Summary
The facility failed to ensure that residents who self-administer medications had appropriate assessments completed by the interdisciplinary team. Specifically, two residents were observed with medications, including Afrin nasal spray, lubricant eye drops, and diclofenac/lidocaine cream, on their bedside tables. Review of their clinical records revealed that neither resident had a documented self-administration evaluation by the interdisciplinary team, as required by facility policy. Interviews with an LPN and a Unit Manager confirmed that these residents should have had self-administration evaluations in their records if they were keeping medications in their rooms. The facility's policy states that residents wishing to self-administer medications must be assessed by nursing staff, with the assessment reviewed by the IDT and physician before approval. Both residents had multiple diagnoses, including hypertension, cataracts, diabetes, and pain, but lacked the necessary documentation to support self-administration of their medications.
Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
Staff failed to ensure a dependent resident with dementia and severe cognitive impairment was dressed appropriately to maintain her dignity and provided with timely incontinence care. On two separate occasions, the resident was observed sitting in a lounge area with her shirt pulled up, exposing her left breast. In both instances, nursing leadership noticed the exposure and adjusted the resident's clothing. Interviews with the Assistant Director of Nursing and Director of Nursing confirmed awareness of the issue and the need for closer monitoring. Additionally, the resident was observed sitting in the lounge for an extended period with bath blankets wrapped around her, emitting a strong odor of urine and bowel movement. The resident was visibly uncomfortable, leaning to one side. After being informed, the Unit Manager and a CNA provided care, finding the resident's brief soaked with urine and a large loose bowel movement. Staff interviews and facility policy confirmed that residents should be checked and changed at least every two hours or as needed, and that perineal care should be performed after episodes of incontinence to maintain cleanliness and comfort.
Failure to Evaluate and Safely Transfer Dependent Resident Using Mechanical Lift
Penalty
Summary
A dependent resident with severe cognitive impairment, dementia, and blindness was transferred using a sit-to-stand mechanical lift without a prior evaluation to ensure the transfer method was safe for her condition. During the transfer, the resident did not hold onto the handlebars as instructed, and the sling strap slipped under her armpits while she was not using her legs to stand. The transfer was completed with staff physically assisting the resident to the bed, despite the resident's refusal and inability to participate as required for safe use of the lift. The resident's care plan indicated total dependence and the need for assistance by two staff members for transfers, but did not specify the use of a sit-to-stand lift. There was no documentation of a safety evaluation for the use of this lift with the resident. Staff interviews confirmed that the assignment sheet was incorrect and that the sit-to-stand lift was not an appropriate transfer method for this resident. Facility policy required checking assignment sheets for approved transfer methods and ensuring residents could safely use mechanical lifts, which was not followed in this instance.
Failure to Ensure Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly drug regimen reviews, including review of the medical chart, for several residents as required. For one resident with diagnoses including Alzheimer's disease, psychotic disorder, severe kidney disease, diabetes, depression, and anxiety, pharmacy reviews were missing for July, with no documentation found for that month despite a change in pharmacy providers. The DON confirmed that neither the current nor previous pharmacy provider could produce the missing review. Another resident with seizure disorder, anxiety, and depression had missing pharmacy reviews for multiple months, including June, July, January, and February, with the DON confirming that several months' reviews were not available after contacting the previous pharmacy. A third resident with hypertension, anxiety disorder, and manic depression also lacked a pharmacy review for July, with the DON unable to locate the required documentation. Facility policy required psychoactive medications to be reviewed in accordance with regulatory requirements, but the required monthly pharmacist reviews were not consistently completed or documented for these residents.
Failure to Ensure Resident Meals Delivered at Safe and Appetizing Temperatures
Penalty
Summary
A deficiency occurred when a resident's meals were repeatedly delivered to her room while she was asleep, resulting in the food sitting unattended and cooling to unappetizing and unsafe temperatures. The resident reported that her meals were served cold and that staff did not always wake her up upon delivery. Observations confirmed that on multiple occasions, the resident was asleep with her meal tray left on her bedside table, and she was unaware that her food had been delivered. When asked, the resident expressed a preference to be awakened for meal delivery, contradicting staff statements that she did not want to be disturbed. Food temperature checks revealed that the meals were below required temperatures, with the eggs measured at 83 degrees Fahrenheit, well under the standard of over 140 degrees Fahrenheit for hot foods. The resident's care plans did not include her preferences regarding meal delivery, despite her need for set-up assistance and her stated wishes. Interviews with staff indicated a lack of clarity about the resident's preferences, and the facility lacked a specific policy for room tray delivery. Additionally, other residents reported receiving cold food in their rooms and felt they should not have to request reheating. Facility documents outlined expectations for timely and safe meal delivery and maintaining proper food temperatures, but these were not followed in practice for this resident.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by two separate incidents involving two residents. In the first incident, a resident reported that a CNA was rough and grouchy while assisting her, which hurt her feelings. The CNA was later suspended pending an investigation. The resident had a history of major depressive disorder, anxiety disorder, and other health issues, and was unable to be interviewed at the time of the survey. In the second incident, another resident reported a care concern with a different CNA, who allegedly yelled at her and her roommate, and scolded her for wanting to wear two briefs. The resident, who had a history of psychotic disorder with hallucinations, major depressive disorder, and dementia, expressed that she felt mistreated and did not want the CNA to care for her again. This resident was also unable to be interviewed at the time of the survey.
Failure to Follow Hoyer Lift Transfer Protocol
Penalty
Summary
The facility failed to ensure that two staff members were present during a Hoyer lift transfer, leading to an accident involving a resident. The incident involved a CNA who attempted to transfer a resident using a Hoyer lift without the assistance of a second staff member, as required by the facility's policy. During the transfer, the resident moved her hands, causing her to slide out of the lift onto a recliner, and then onto the floor due to poor positioning. The resident, who had a history of major depressive disorder, pain, anxiety disorder, frontotemporal neurocognitive disorder, moderate protein-calorie malnutrition, and difficulty walking, complained of pain following the incident and was administered pain medication. The root cause of the fall was identified as the CNA's decision to perform the transfer alone, despite being aware of the policy requiring two staff members for such procedures. The CNA admitted to knowing the requirement but chose not to wait for assistance. This incident was documented in the resident's clinical record and was further corroborated by an IDT progress note. The facility's policy on mechanical lift transfers, which mandates the presence of a second staff member, was not adhered to, resulting in the resident's fall and subsequent pain.
Failure in Narcotic Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure proper administration and documentation of narcotic medications for two residents, leading to a deficiency in pharmaceutical services. On 10/11/24, several residents reported not receiving their medications from RN 10, an agency nurse. The Electronic Medication Administration Record (EMAR) for Resident C showed no documentation of receiving prescribed doses of Cyclobenzaprine and Norco, despite the narcotic count sheet indicating administration by RN 10. Similarly, Resident D's EMAR lacked documentation for Oxycodone administration, although the narcotic sheet showed it was signed out by RN 10. Resident D reported receiving only Tylenol and not the prescribed Oxycodone, corroborated by a handwritten document noting RN 10's strange behavior. Resident H also experienced a lack of documentation for Oxycodone administration on the same date, with the narcotic sheet indicating it was signed out by RN 10. The facility's policy required documentation of all administered medications in the EMAR and on the narcotic sheet, which was not followed in these cases. The failure to adhere to the medication administration policy resulted in a deficiency, as the residents did not receive their prescribed narcotic medications, and the documentation was not accurately maintained.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a contracted housekeeping staff member. The incident occurred when a housekeeper was found on top of a resident in the dementia unit, with his pants down and the resident's gown and brief pulled up and open, respectively. This was witnessed by the Housekeeping Supervisor, who immediately intervened and called the police. The resident involved, identified as having severe cognitive impairment due to Alzheimer's disease and other conditions, was unable to understand or communicate effectively, which contributed to her vulnerability. The resident's care plan indicated she required maximum assistance with personal care and had a self-care performance deficit due to her dementia. She was also noted to have a functional limitation in her range of motion to both lower extremities. The resident's primary language was not English, and she was rarely understood even with translation assistance. At the time of the incident, the resident was found lying in bed, staring blankly at the ceiling, and did not appear to be in distress. The facility's policy on abuse, neglect, and exploitation, dated January 2024, emphasized the right of each resident to be free from abuse. However, the incident revealed a failure in the facility's protective measures, as the housekeeper was able to access and assault the resident. The housekeeper had a history of verbal warnings for tardiness and unsatisfactory job performance, which were documented in his employee file. The deficiency was identified as an immediate jeopardy situation, indicating a serious breach in resident safety and care standards.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to ensure a resident with dementia was free from physical abuse. A staff member, identified as CNA 1, was observed by another staff member, CNA 2, pulling a resident by the ears to remove him from another resident's room. This incident resulted in redness on the resident's ears. The resident, who was residing in the memory care unit, had a medical history that included dementia, chronic obstructive pulmonary disease, anemia, and peripheral vascular disease. The incident was reported to the Director of Nursing (DON) by CNA 2, who witnessed the abuse and intervened to protect the resident. The clinical records and nursing progress notes indicated that the resident's left ear was slightly red following the incident, and the redness was observed by a nurse practitioner the following day. CNA 1 claimed that the redness was due to shaving the resident earlier in the day, but CNA 2 reported that CNA 1 twisted the resident's ear while reprimanding him for entering another resident's room. The facility's policy on abuse, neglect, and exploitation emphasizes the residents' right to be free from abuse, and the incident was documented as a violation of this policy.
Misappropriation of Residents' Property and Financial Assets
Penalty
Summary
The facility failed to protect the personal property of two residents, leading to incidents of misappropriation. In the first case, a resident's daughter discovered that her father's AirPods were missing during a visit. The AirPods were later pinged to the address of a CNA employed at the facility. Despite the CNA's denial of involvement, the facility terminated her employment due to the evidence linking the AirPods to her address. This incident highlights a lapse in the facility's ability to secure residents' belongings and prevent unauthorized access by staff. In the second case, a resident's son noticed an unauthorized charge on his mother's credit card statement for a restaurant purchase. The resident was unable to leave the facility independently, suggesting that someone else used her card without permission. The facility's investigation revealed that the transaction was made in person at a nearby restaurant. Despite the resident's refusal to lock up her valuables, the facility failed to ensure the security of her financial assets, resulting in the misuse of her credit card.
Privacy Breach in Medication List Handling
Penalty
Summary
The facility failed to ensure the privacy of a resident's medication list during an admission process, affecting one of the five residents reviewed for resident-identifiable information. The incident involved Resident C, whose medication information was incorrectly sent to the hospital. This error led to a significant delay in administering the correct medications to the resident. The mistake was identified when the resident's niece discovered that the medication list in the envelope was for another resident, Resident N, instead of Resident C. The niece reported the discrepancy to the hospital staff, who then contacted the facility to obtain the correct medication list. The error occurred when two LPNs, LPN 8 and LPN 9, were preparing Resident C for a transfer to an appointment. LPN 8 printed the resident's face sheet, while LPN 9 printed the medication list for another resident, Resident N. Without verifying the name on the medication sheet, LPN 8 placed it in the envelope with the face sheet, which was then sent to the hospital. This breach of privacy was a violation of HIPAA regulations, as it involved the inappropriate disclosure of protected health information (PHI).
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harcourt Terrace Nursing And Rehabilitation | 1.9 mi | ★★★★★ | 27 | 0 |
| Marquette | 2.2 mi | ★★★★★ | 3 | 0 |
| Brickyard Healthcare - Willow Springs Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Spring Mill Meadows | 2.4 mi | ★★★★★ | 4 | 0 |
| St Augustine Home For The Aged | 2.5 mi | ★★★★★ | 0 | 0 |
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