Hooverwood

In the surveyor’s words

From the most serious findings on record at Hooverwood, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 30, 2025

  Based 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). […]

• Immediate jeopardy, isolatedF600Dec 27, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689May 7, 2021

  Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision; windows were secure; staff were trained to prevent elopement and respond to actual elopement; codes to elopement alarms were not openly visible and the family and police were notified of an elopement in a timely manner for 3 of 3 residents reviewed with wandering and exit-seeking behaviors (Residents C, D and G). This failure resulted in Resident C successfully exiting the secured dementia unit through a window on 4/26/21. The immediate jeopardy began on 4/26/21 when Resident C, who had Alzheimer's dementia, severely impaired cognitive status, and exhibited exit seeking behaviors and verbalizations since admission on 4/14/21, was not monitored between 3:50 a.m. […]

• Actual harm, isolatedF684Mar 6, 2024

  Based 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. […]

• Actual harm, isolatedF689Jul 17, 2023

  Based on observation, interview and record review, the facility failed to protect a resident from injury during a transfer when the CNA did not follow transfer instructions for 1 of 3 residents reviewed for accidents. (Resident 2) Resident 2 sustained a fracture to her femur when she was lowered to the floor. Finding includes: An incident report filed with the Indiana Department of Health indicated Resident 2 sustained a fall, on 06/05/23 at approximately 2:00 p.m., when she became weak during a transfer. The Nurse Practitioner assessed the resident, and a STAT (immediate) x-ray was ordered. The x-ray showed an acute right transverse distal femur fracture (a fracture to the leg bone between the hip and the knee). […]