Hooverwood

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Date Set (MDS) assessments were accurately coded for 5 of 7 residents reviewed for resident assessments. (Resident 6, 8, 22, 46, and 105)

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were followed, medications were administered according to the ordered parameters, and a daily weight was obtained for 4 of 4 residents reviewed for quality of care. (Resident 130, 16, 108 and 14)Findings Include: 1. The clinical record for Resident 130 was reviewed on 4/15/26 at 3:04 p.m. The diagnoses included, but were not limited to, congestive heart failure (CHF), acute osteomyelitis (a serious bone infection) of the right ankle and foot, cognitive communication deficit, hypertension, and malignant neoplasm of the prostate. A care plan, dated 1/21/26, indicated Resident 130 had a diagnosis of congestive heart failure. Interventions included, but were not limited to, monitoring the resident's weight daily. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a call light was in reach for 1 of 1 resident reviewed for accommodation of needs. (Resident 11)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication was labeled with an open date in 3 of 5 medication carts reviewed for medication storage. (1B [NAME] Medication Cart, 2B East Medication Cart and 1A East Medication Cart)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with a diagnosis of dementia who resided on a secured locked unit and at risk of elopement did not exit the facility unsupervised for 1 of 3 residents reviewed for accidents. (Resident B) Resident B wandered approximately 0.4 miles away from the facility and had crossed a two-lane road. The immediate jeopardy began, on 12/23/25, when Resident B exited the facility unsupervised and without the staff's knowledge while wearing a wanderguard device (a wearable device used to alert staff when a resident approached restrictive areas/doors). The resident exited the secured locked unit through an unlocked stairway door, went down the stairwell to the first floor, and exited the facility through an unlocked but alarmed door. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a dependent resident was free from neglect and was provided incontinence care during an eight-hour shift for 1 of 3 residents reviewed for neglect. (Resident E) The deficient practice was corrected on 6/26/25, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic medications were free from theft of an employee for 1 of 3 residents reviewed for misappropriation of property. (Resident C) The deficient practice was corrected on 12/17/25, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or residents' representatives were provided a notice of the facility bed hold policy at the time of transfer, or in cases of emergency transfer, within 24 hours for 5 of 6 residents reviewed for transfer and discharge. (Resident 80, 9, 66, 108 and 138)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had self-medication administration assessments completed by the interdisciplinary team for 2 of 2 residents reviewed for self-medication administration. (Resident 73 and 77)

Inspectors wroteBased on interview and record review, the facility failed to ensure the ombudsman and resident, or resident's representative was notified in writing of the reason for the resident's transfer and discharge to the hospital for 2 of 6 residents reviewed for transfer and discharge. (Resident 80 and 9)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff dressed a resident in a manner to avoid allowing her breast to be exposed and to provide incontinence care in a timely manner for 1 of 1 dependent resident reviewed for activities of daily living (ADL) care. (Resident 28)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a dependent resident was evaluated prior to being transferred with a sit-to-stand mechanical lift to ensure a safe transfer for 1 of 3 residents reviewed for accidents hazards. (Resident 28)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents medications were reviewed monthly by the pharmacist for 3 of 5 residents reviewed for unnecessary medications. (Resident 55, 91 and 92)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an as needed (PRN) psychotropic medication was limited to 14 days and an Abnormal Involuntary Movement Scale (AIMS) assessment was completed for a resident taking a psychotropic medication for 2 of 5 residents reviewed for unnecessary medications. (Residents 137 and 91)

Inspectors wroteBased on observation, interview and record review, 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. (Resident 34)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 12 residents reviewed for resident rights. (Resident J and K). The deficient practice was corrected on 11/5/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure two staff members completed a Hoyer lift transfer to prevent an accident for 1 of 3 residents reviewed for accidents. (Resident J) The deficient practice was corrected on 11/11/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member followed the policy and procedure when administering narcotics to 2 of 7 residents reviewed for pharmaceutical services. (Residents C, D and H) The deficient practice was corrected on 10/15/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a staff member for 1 of 1 resident reviewed for abuse. (Resident B) Resident B was sexually assaulted by a contracted housekeeping staff member. The immediate jeopardy began on 12/21/24, when Housekeeper 2 was observed to be laying on top of Resident B. Housekeeper 2's pants were down, and his private parts were exposed. Resident B's gown was pulled up, her brief was open, and her private area was exposed. The Interim Executive Director (ED) and Interim Director of Nursing were notified of the immediate jeopardy on 12/26/24 at 2:42 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected on 12/22/24, prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical abuse related to a staff member who grabbed a resident with dementia, who was residing on the memory care unit, by his ears and pulled him out of another resident's room for 1 of 4 residents reviewed for abuse. (Resident D) The deficient practice was corrected on 9/23/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' personal property and credit card was kept safe and secure during their admission for 2 of 3 residents reviewed for misappropriation of property. (Residents E and F) The deficient practice was corrected on 8/23/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medication list was kept private during her admission for 1 of 5 residents reviewed for resident-identifiable information. (Resident C) The deficient practice was corrected on 9/30/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to effectively administer back blows for a choking resident in accordance with treatment guidelines established by the facility and failed to ensure the plan of care was effectively revised with accurate care information (Resident S). This deficient practice resulted in Resident S experiencing a choking episode with a change in the level of consciousness which required emergent treatment. The facility also failed to ensure residents maintained upright positioning while sitting in chairs (Resident V and F), to ensure the physician was notified for blood sugars above specified parameters and to ensure weights were completed daily (Resident 99) for 4 of 4 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was an ongoing program of cognitively stimulating activities for residents diagnosed with dementia for 4 of 9 residents reviewed for activities. (Resident I, F, U and V)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored according to the pharmacy directions, were labeled and dated, and schedule II medication cards were not compromised for 4 of 5 carts reviewed for medication storage. (2A east, 2A west, 2B east and 2B west)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were in place for residents with transmission based precautions (TBP), to ensure staff performed hand hygiene, disinfected equipment, and used the appropriate personal protective equipment (PPE), to ensure infection control policies were reviewed and updated annually, and to ensure indwelling urinary catheter bags were not contaminated for 4 of 7 residents reviewed for infection control. (Resident Q, 14, 106 and 96)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident had a self-medication administration assessment and to ensure medications were not left unattended in a resident's room for 1 of 3 residents reviewed for medication administration. (Resident 99)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a PASARR (Preadmission Screening and Resident Review) level II was recorded on the Minimum Data Set (MDS) assessment for 2 of 3 residents reviewed for PASARR Minimum Data Set assessments. (Resident 105 and 58)

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement resident specific interventions to address the identified limitations in the ability to effectively communicate requests and needs, to listen to others, and to participate in social conversation for 1 of 3 residents reviewed for activities of daily living (ADL) care related to communication. (Resident K)

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement resident specific interventions to ensure a cognitively impaired resident with a past history of elderly abuse received the necessary services to meet her grooming, bathing, and clothing needs for 1 of 2 residents reviewed for activities of daily living (ADL) care. (Resident T)

Inspectors wroteBased on interview and record review, the facility failed to determine the root cause and implement new interventions for falls for 1 of 8 residents reviewed for accidents. (Resident R)

Inspectors wroteBased on observation, interview and record review, the facility failed to label the oxygen tubing and to administer the correct liters of oxygen flow for 2 of 4 residents reviewed for respiratory care. (Resident 117 and 3)

Inspectors wroteBased on observation, interview and record review, the facility failed to keep stored food items covered in 1 of 1 cold storage room reviewed for safe and sanitary conditions in the kitchen. (cold storage room)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 3 of 6 residents reviewed for medication administration. (Residents B, C and D)