Inspection Report Summary
The most recent inspection on June 27, 2025, identified one deficiency related to a failure to ensure a resident was treated with respect and dignity, resulting in termination of the involved employee. Earlier inspections showed a pattern of deficiencies primarily involving emergency preparedness and life safety code compliance, medication management, behavioral health services, and maintaining a safe and sanitary environment. Several complaint investigations were substantiated with deficiencies cited for issues such as care plan updates, abuse investigations, behavioral health monitoring, and supervision of residents at risk, while many complaints were found unsubstantiated or corrected upon revisit. No fines, immediate jeopardy findings, or license suspensions were listed in the available reports. The facility’s recent inspections indicate some improvement in emergency preparedness and complaint corrections, though issues related to resident care and environment have recurred over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
33.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
693% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
79 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Date: Jun 27, 2025
Visit Reason
This visit was conducted for the investigation of complaint IN00460364.
Complaint Details
Complaint IN00460364 was investigated and found to have no deficiencies related to the allegations. The unrelated finding involved verbal abuse by a staff member, who was subsequently terminated.
Findings
No deficiencies related to the complaint allegations were cited; however, an unrelated deficiency was found involving a failure to ensure a resident was treated with respect and dignity. The facility terminated the involved employee and implemented corrective actions including resident assessments and staff re-education.
Deficiencies (1)
Facility failed to ensure a resident was treated with respect and dignity, evidenced by a Certified Nursing Assistant yelling at a resident during care.
Report Facts
Census SNF/NF beds: 73
Census Residential beds: 6
Total Census: 79
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 69
Census Payor Type Other: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) 2 | Named as the staff member who yelled at Resident B and was terminated | |
| Licensed Practical Nurse (LPN) 3 | Reported CNA 2 was loud with Resident B and intervened | |
| Director of Nursing (DON) | Received report of incident and provided termination documentation |
Inspection Report
Re-Inspection
Census: 73
Capacity: 125
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 04/16/25.
Findings
At this PSR Emergency Preparedness survey and Life Safety Code survey, Hanover Nursing Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 125
Census: 73
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: May 1, 2025
Visit Reason
This visit was for the investigation of Nursing Home Complaints IN00457113, IN00457358, and Residential Complaint IN00458545, in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey and investigation of Nursing Home Complaints IN00455300 and IN00455916 completed on March 27, 2025.
Complaint Details
Complaint IN00457113 - No deficiencies related to the allegations are cited. Complaint IN00457358 - No deficiencies related to the allegations are cited. Complaint IN00458545 - No deficiencies related to the allegations are cited. Complaint IN00455300 - Corrected. Complaint IN00455916 - Corrected.
Findings
No deficiencies related to complaints IN00457113, IN00457358, and IN00458545 were cited. Complaints IN00455300 and IN00455916 were corrected. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 70
Census Bed Type - Residential: 4
Total Census: 74
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 7
Inspection Report
Re-Inspection
Census: 74
Capacity: 74
Deficiencies: 0
Date: May 1, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the investigation of Nursing Home complaints IN00455300 and IN00455916 completed on March 27, 2025. It also included investigations of additional Nursing Home and Residential Complaints IN00457113, IN00457358, and IN00458545.
Complaint Details
Complaint IN00455300 - Corrected. Complaint IN00455916 - Corrected. Complaint IN00457113 - No deficiencies related to the allegations are cited. Complaint IN00457358 - No deficiencies related to the allegations are cited. Complaint IN00458545 - No deficiencies related to the allegations are cited.
Findings
Aperion Care Hanover 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 investigations of Nursing Home Complaints IN00455300 and IN00455916. Complaints IN00455300 and IN00455916 were corrected, and no deficiencies were cited related to complaints IN00457113, IN00457358, and IN00458545.
Report Facts
Census SNF/NF: 70
Census Residential: 4
Total Census: 74
Total Capacity: 74
Medicare Census: 3
Medicaid Census: 60
Other Payor Census: 7
Inspection Report
Routine
Census: 71
Capacity: 125
Deficiencies: 26
Date: Apr 16, 2025
Visit Reason
Routine Emergency Preparedness and Life Safety Code survey conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Emergency Preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, Communication Plan, Training and Testing Plan, and failure to conduct required emergency preparedness training and exercises. Life Safety Code deficiencies included obstructed exit discharge paths, missing exit door code postings, doors not opening easily, missing 'No Exit' signage, incomplete maintenance of smoke detectors, sprinkler system issues, fire alarm system inspection deficiencies, and electrical safety concerns.
Deficiencies (26)
Failed to review and update the Emergency Preparedness Plan (EPP) annually.
Failed to review and update the Emergency Preparedness Plan's Communication Plan annually.
Failed to ensure the emergency preparedness communication plan includes current staff names and contact information.
Failed to review and update the Emergency Preparedness Plan's Training and Testing Plan annually.
Failed to conduct annual training for the Emergency Preparedness Program.
Failed to conduct required emergency preparedness exercises including full-scale exercises.
Failed to implement emergency power system inspection, testing, and maintenance requirements including documentation of load testing.
Exit discharge paths obstructed by parked cars.
Exit doors not posted with codes to actuate door release and some doors did not open easily on first try.
One courtyard door not posted with 'No Exit' sign.
Incomplete documentation for preventative maintenance of battery operated smoke alarms in resident rooms.
Two hazardous area doors lacked self-closing devices; one door failed to self-close and latch positively.
Cooking appliance not returned to approved design location after maintenance or cleaning.
Failed to maintain fire alarm system with required semi-annual visual inspections.
Fire department connection signage faded and illegible.
Sprinkler piping subjected to external loads by wires and conduit draped across sprinkler heads; grounding wire attached to sprinkler pipe.
Failed to maintain weekly inspection of dry pipe sprinkler system gauges and valves prior to July 2024.
Kitchen corridor door propped open with door stop, preventing proper closing and smoke resistance.
Failed to conduct quarterly fire drills on unexpected days and times; drills clustered near end of month.
One smoking area had temporary uncovered cigarette butt receptacles that were not emptied after use.
Failed to ensure annual inspection and testing of all fire door assemblies.
Failed to exercise emergency generator monthly for 12 months and maintain documentation of load testing.
Power strips used as substitute for fixed wiring to power high current draw equipment in therapy and MDS office.
Power strips in resident rooms lacked required UL rating.
Failed to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE).
Missing smoke detector in resident sleeping Room 65.
Report Facts
Certified beds: 125
Census: 71
Deficiencies cited: 27
Fire drills conducted near end of month: 9
Monthly generator load tests missing documentation: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jay Nowlin | Administrator | Signed report and present at exit conference |
| Maintenance Director | Interviewed throughout inspection, acknowledged deficiencies and corrective actions |
Inspection Report
Recertification
Census: 70
Capacity: 74
Deficiencies: 11
Date: Mar 27, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00455300, IN00455842, and IN00455916. It included a State Residential Licensure Survey.
Complaint Details
Complaint IN00455300 - Federal/State deficiencies related to the allegations are cited at F584 and F925. Complaint IN00455842 - No deficiencies related to the allegations are cited. Complaint IN00455916 - Federal/State deficiencies related to the allegations are cited at F584 and F925.
Findings
The facility was found deficient in multiple areas including failure to have State survey results available for viewing, unsafe and unclean environment in certain areas, medication administration errors, nutrition documentation issues, pharmacy service deficiencies, improper medication storage, inadequate infection control practices, pest control issues, and untimely review of residents' service plans.
Deficiencies (11)
Failed to have State survey results available to view for 2 of 6 days during the survey.
Failed to provide a clean and safe environment related to a dirty shower room and unsafe walkways for 2 of 4 facility areas reviewed.
Failed to administer prescribed insulin medications for 1 of 19 residents reviewed.
Failed to monitor meal consumption and have supplements available for 1 of 3 residents reviewed for nutrition.
Failed to ensure medication was available for 1 of 19 residents reviewed for pharmacy services.
Failed to address pharmacy recommendations for 3 of 5 residents reviewed for medication irregularities.
Failed to store medications appropriately in medication storage rooms and carts.
Failed to follow appropriate guidelines related to the use of hairnets in the kitchen for 3 of 3 kitchen observations.
Failed to follow infection control guidelines related to enhanced barrier precautions for 3 of 3 wound care observations.
Failed to ensure an effective pest control program related to gnats or drain flies in residents' bathrooms and bedrooms.
Failed to ensure residents' Service Plans were reviewed in a timely manner for 2 of 7 residents reviewed for Evaluation of Needs.
Report Facts
Survey dates: March 20, 21, 24, 25, 26, and 27, 2025
Census Bed Type: 74
Census Payor Type: 70
Deficiencies cited: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jay Nowlin | Administrator | Signed report and involved in plan of correction |
| Licensed Practical Nurse 7 | Mentioned in medication administration and maintenance request findings | |
| Director of Nursing | DON | Interviewed regarding medication administration, pharmacy recommendations, and service plan reviews |
| Certified Nurse Aide 8 | CNA | Mentioned in fall incident and maintenance request |
| Licensed Practical Nurse 2 | LPN | Observed providing wound care without gown |
| Licensed Practical Nurse 3 | LPN | Interviewed about wound care and medication cart cleanliness |
| Licensed Practical Nurse 10 | LPN | Observed removing loose pills from medication cart |
| Dietary Manager | Observed with improper hairnet use | |
| Cook 4 | Observed with improper hairnet use | |
| Cook 5 | Observed with improper hairnet use | |
| Corporate Dietary Consultant | Observed with improper hairnet use |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00448227 completed on January 13, 2025.
Complaint Details
Investigation of Complaint IN00448227 completed on January 13, 2025. Complaint was corrected.
Findings
Aperion Care Hanover was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation. The complaint IN00448227 was corrected.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451749.
Complaint Details
Complaint IN00451749 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00451749 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 74
Census Bed Type - Residential: 4
Total Census: 78
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 64
Census Payor Type - Other: 9
Total Census Payor: 74
Inspection Report
Complaint Investigation
Census: 79
Capacity: 84
Deficiencies: 1
Date: Jan 13, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00448227 related to care plan timing and revision.
Complaint Details
Complaint IN00448227 was substantiated with a federal/state deficiency cited at F657 related to care plan timing and revision.
Findings
The facility failed to ensure care planned interventions were updated related to a resident's behaviors for 1 of 3 residents reviewed. Specifically, care plans for Resident C were not updated timely following behavioral incidents.
Deficiencies (1)
Failed to ensure care planned interventions were updated related to a resident's behaviors for 1 of 3 residents reviewed for care plan revision.
Report Facts
Census SNF/NF: 79
Census Residential: 5
Total Census: 84
Medicare Census: 3
Medicaid Census: 74
Other Payor Census: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Jenkins | Administrator | Signed the report and provided the resident's complete care plan |
| Director of Nursing | Intervened during resident incident and involved in care plan revision process | |
| Social Service Director | Interviewed regarding care plan updates for Resident C | |
| MDS Coordinator | Interviewed and acknowledged mistake updating wrong care plan |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 76
Deficiencies: 0
Date: Oct 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00442956, IN00443747, IN00444881, and IN00445163 at Aperion Care Hanover.
Complaint Details
Complaints IN00442956, IN00443747, IN00444881, and IN00445163 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of the complaints.
Report Facts
Census SNF/NF: 71
Census Residential: 5
Total Census: 76
Total Capacity: 76
Medicare Census: 6
Medicaid Census: 64
Other Payor Census: 1
Inspection Report
Follow-Up
Census: 77
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00440161 completed on August 20, 2024, and was conducted in conjunction with the PSR to the Investigation of Nursing Home Complaint IN00442016 completed on September 4, 2024.
Complaint Details
Complaint IN00440161 and Complaint IN00442016 were investigated and found to be corrected.
Findings
Both complaints IN00440161 and IN00442016 were found to be corrected. The facility 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 Investigation of Complaints.
Report Facts
Census Bed Type - SNF/NF: 72
Census Bed Type - Residential: 5
Total Census: 77
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 1
Total Census Payor: 72
Inspection Report
Re-Inspection
Census: 77
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Nursing Home Complaints IN00442016 and IN00440161 to verify correction of previously identified deficiencies.
Complaint Details
This visit was related to complaints IN00442016 and IN00440161. Both complaints were corrected as of this visit.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaints investigated. Both complaints IN00442016 and IN00440161 were corrected.
Report Facts
Census Bed Type SNF/NF: 72
Census Bed Type Residential: 5
Total Census: 77
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 65
Census Payor Type Other: 1
Total Census Payor: 72
Inspection Report
Complaint Investigation
Census: 67
Capacity: 73
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
This visit was for the investigation of complaints IN00442016 and IN00442435. Complaint IN00442016 resulted in a cited deficiency, while complaint IN00442435 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00442016 was substantiated with a state/federal deficiency cited at F742. Complaint IN00442435 was not substantiated with any deficiencies.
Findings
The facility failed to ensure that a resident with psychosocial adjustment difficulties and a history of trauma received appropriate treatment to attain the highest practicable mental well-being. The investigation focused on Resident C, who exhibited behavioral issues and had not received psychiatric services despite indications of need.
Deficiencies (1)
Failed to ensure a resident who displayed psychosocial adjustment difficulties and a history of trauma received appropriate treatment to attain the highest practicable mental well-being.
Report Facts
Census SNF/NF beds: 67
Census Residential beds: 6
Total Capacity: 73
Medicare census: 5
Medicaid census: 61
Other census: 1
Total census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Jenkins | Administrator | Signed as facility administrator on the report |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00439814, IN00439916, and IN00440161) concerning alleged violations at the facility.
Complaint Details
Complaint IN00440161 was substantiated with a deficiency cited. The investigation revealed that CNA 3 cursed at Resident B, but the facility failed to conduct a thorough investigation or suspend the employee. The Administrator educated CNA 3 on customer service but did not pursue further investigation. Resident B later denied hearing the curse. The facility policy prohibits abuse and mandates prompt and aggressive investigations.
Findings
No deficiencies were cited related to complaints IN00439814 and IN00439916. A federal/state deficiency was cited related to complaint IN00440161 for failure to thoroughly investigate an abuse allegation involving Resident B and CNA 3.
Deficiencies (1)
Failure to thoroughly investigate 1 of 1 abuse allegations reviewed involving Resident B and CNA 3.
Report Facts
Census Bed Type - SNF/NF: 62
Census Bed Type - Residential: 5
Total Census: 67
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 57
Census Payor Type - Other: 1
CNA 3 Work Hours on 07/31/24: 60
CNA 3 Work Hours on 08/01/24: 721
Suspension Duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Jenkins | Administrator | Named in relation to the abuse investigation and deficiency findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00438629 completed on July 18, 2024.
Complaint Details
Investigation of Complaint IN00438629 completed with findings of compliance.
Findings
Aperion Care Hanover 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 to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 70
Capacity: 75
Deficiencies: 1
Date: Jul 18, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00438629, which included investigations of Residential Complaints IN00436046 and IN00436077, as well as a COVID-19 Focused Infection Control Survey.
Complaint Details
The complaint investigation was triggered by Nursing Home Complaint IN00438629. The allegation was substantiated with a deficiency cited at F557. Residential Complaints IN00436046 and IN00436077 were investigated with no deficiencies cited.
Findings
The facility was found to have a state/federal deficiency related to Nursing Home Complaint IN00438629 concerning a resident's rights to personal possessions during a temporary room move due to COVID-19. No deficiencies were cited for the two residential complaints. The facility was found in compliance with residential complaint investigations and COVID-19 quality assurance walk through.
Deficiencies (1)
Facility failed to ensure a resident's rights were honored related to their personal possessions during a temporary room move due to COVID-19 exposure.
Report Facts
Census SNF/NF: 70
Census Residential: 5
Total Capacity: 75
Medicare Census: 5
Medicaid Census: 64
Other Payor Census: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Jenkins | Administrator | Named as the facility administrator on the report |
| Director of Nursing | Interviewed regarding the temporary room move and resident rights | |
| Certified Nurse Aide 2 | Interviewed and observed resident belongings in the previous room | |
| Assistant Director of Nursing | Provided the facility policy titled 'Resident Rights' |
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00430588 completed on April 25, 2024.
Complaint Details
Complaint IN00430588 was investigated and found to be corrected.
Findings
Aperion Care Hanover 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 Complaint IN00430588. The complaint and unrelated findings were corrected.
Report Facts
Census SNF/NF beds: 65
Census Residential beds: 6
Total Census: 71
Census Medicare: 3
Census Medicaid: 59
Census Other payor: 3
Total Census Payor Type: 65
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints identified by numbers IN00435908, IN00435237, IN00435172, IN00434882, IN00434493, and IN00434249.
Complaint Details
The investigation covered six complaints (IN00435908, IN00435237, IN00435172, IN00434882, IN00434493, IN00434249), all of which resulted in no deficiencies being cited.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with relevant federal and state regulations.
Report Facts
Census Bed Type - SNF/NF: 63
Census Bed Type - Residential: 7
Total Census: 70
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 1
Inspection Report
Complaint Investigation
Census: 65
Capacity: 70
Deficiencies: 5
Date: Apr 24, 2024
Visit Reason
Investigation of Complaints IN00431249 and IN00430588. Complaint IN00431249 had no deficiencies related to allegations; Complaint IN00430588 had a State/Federal deficiency cited at F740.
Complaint Details
Complaint IN00431249 had no deficiencies related to allegations. Complaint IN00430588 had a State/Federal deficiency cited at F740 related to behavioral health services and other unrelated deficiencies.
Findings
The facility failed to timely report investigation outcomes to the Indiana Department of Health for 9 of 9 incidents. The facility also failed to administer medications and monitor residents with behavioral health concerns for 2 of 4 residents reviewed. Additionally, the kitchen was found unclean and unsanitary, and the facility failed to maintain an effective pest control program with evidence of rodents.
Deficiencies (5)
Failed to report investigation outcomes to IDOH within 5 working days for 9 incidents involving residents.
Failed to administer medications and monitor residents with behavioral health concerns for 2 of 4 residents reviewed.
Failed to provide a clean and sanitary kitchen; observed open doors, food debris, trash overflow, and incomplete cleaning schedules.
Failed to maintain an effective pest control program; observed mouse in SSD office, mouse droppings in kitchen, and evidence of rodents.
Failed to provide a clean and sanitary kitchen for residential side; similar issues with food debris, trash overflow, and pest evidence.
Report Facts
Residents present: 65
Total licensed capacity: 70
Reported incidents: 9
Residents affected by medication/monitoring deficiency: 2
Residents affected by kitchen sanitation deficiency: 63
Residents affected by pest control deficiency: 65
Residents affected by residential kitchen sanitation deficiency: 5
Inspection Report
Re-Inspection
Census: 65
Capacity: 125
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 01/30/24.
Findings
At this PSR, Aperion Care Hanover was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including Medicare/Medicaid participation standards and fire safety codes.
Report Facts
Certified beds: 125
Census: 65
Inspection Report
Re-Inspection
Census: 64
Capacity: 70
Deficiencies: 0
Date: Feb 26, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the Investigation of Complaint IN00425296 completed on January 10, 2024.
Complaint Details
Complaint IN00425296 - Corrected
Findings
Hanover Nursing Center 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 Complaint IN00425296.
Report Facts
Census SNF/NF: 64
Census Residential: 6
Total Capacity: 70
Census Medicare: 8
Census Medicaid: 55
Census Other: 1
Total Census: 64
Inspection Report
Complaint Investigation
Census: 63
Capacity: 69
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427330 and IN00428495.
Complaint Details
Complaint IN00427330 and Complaint IN00428495 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00427330 and IN00428495 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 63
Census Bed Type - Residential: 6
Total Capacity: 69
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 51
Census Payor Type - Other: 1
Total Census Payor: 63
Inspection Report
Routine
Census: 61
Capacity: 125
Deficiencies: 16
Date: Jan 30, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare/Medicaid participation requirements and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code, and other regulatory standards. Deficiencies included failure to conduct required emergency plan exercises, incomplete generator testing documentation, improperly maintained fire safety equipment, inaccessible egress doors, missing or damaged fire safety signage, and incomplete fire drill documentation.
Deficiencies (16)
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Failed to maintain complete written record of monthly generator load testing for 12 months and weekly inspections for 52 weeks.
Ceiling light and heater units in bathrooms showed signs of overheating with melted vents.
Means of egress through locked exit doors were not readily accessible due to unknown or missing door release codes.
Failed to post NO EXIT signs on doors that could be mistaken for exits.
Hazardous area storage room door was not self-closing.
Failed to perform semi-annual visual inspection of fire alarm system devices.
Sprinkler system inspections were incomplete with missing weekly gauge inspections and monthly control valve inspections; gaps and holes around sprinkler piping and support rods.
Corridor doors impeded from closing properly; one kitchen door held open with wedge; one kitchen door lacked proper locking hardware.
Smoke barrier doors failed to close completely and had paint covering fire rating tags.
Electrical wiring was exposed or improperly secured in multiple locations.
Fire safety plan did not address removal of equipment from corridors during emergencies or staff response to battery operated smoke alarms in resident rooms.
Fire drill documentation was missing for multiple shifts and quarters in 2023.
Failed to provide documentation of annual inspection of oxygen room fire door assembly.
Power strips and multi-plug adapters were used improperly as substitutes for fixed wiring in multiple locations.
Failed to provide documentation of annual testing of nonhospital-grade electrical receptacles in resident rooms.
Report Facts
Certified beds: 125
Census: 61
Missing monthly generator load test documentation: 9
Missing monthly sprinkler system control valve inspections: 2
Missing fire drill documentation: 7
Cigarette butts in trash: 100
Cigarette butts in trash: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Jenkins | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to multiple findings and interviews |
Inspection Report
Recertification
Census: 8
Deficiencies: 14
Date: Jan 10, 2024
Visit Reason
This visit was for a State Residential Licensure Survey, including a Recertification and State Licensure Survey and the Investigation of multiple complaints.
Complaint Details
Complaint IN00425296 resulted in a State/Federal deficiency related to the allegation cited at F686. Other complaints IN00424607, IN00424285, IN00423795, IN00423420, and IN00422985 had no deficiencies cited.
Findings
The facility was found deficient in multiple areas including medication self-administration assessment, abuse investigation, transfer/discharge documentation, care plan updates, quality of care related to fall assessment, pressure ulcer care, urinary tract infection treatment, nurse staffing posting, pharmacy services, medication storage, food safety, antibiotic stewardship, COVID-19 immunization, fire drills, and medication administration documentation.
Deficiencies (14)
Failed to ensure a resident that self-administered medications was appropriately assessed for self-administration.
Failed to thoroughly investigate and monitor an alleged resident to resident abuse.
Failed to provide appropriate transfer/discharge paperwork and assessments for residents reviewed for transfer/discharge.
Failed to update a resident's plan of care related to preferences.
Failed to properly assess a resident after a fall for quality of care.
Failed to complete weekly assessments and measurements related to pressure ulcers for residents reviewed.
Failed to ensure a resident with a urinary tract infection received antibiotic treatment in a timely manner.
Failed to post nurse staffing daily for 3 of 7 days observed.
Failed to provide routine and emergency drugs and biologicals in accordance with regulations, including medication reconciliation and verifying diagnosis for antibiotic administration.
Failed to maintain clear written policies and procedures on medication assistance and to provide ongoing training to ensure competence of medication staff.
Failed to store food safely, monitor the dishwasher, and provide a clean kitchen environment.
Failed to track antibiotic use for residents reviewed for antibiotic stewardship.
Failed to provide a COVID-19 immunization in a timely manner for a resident reviewed.
Failed to regularly conduct fire drills for 4 of the 12 months reviewed.
Report Facts
Survey dates: January 2, 3, 4, 5, 8, 9, and 10, 2024
Census Bed Type: 74
SNF/NF beds: 66
Residential beds: 8
Medicare census: 7
Medicaid census: 58
Other census: 1
Fire drills missing: 4
Medication audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Jenkins | Administrator | Signed the report |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding medication reconciliation and fall assessment |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding antibiotic stewardship and medication storage |
| LPN 7 | Licensed Practical Nurse | Observed medication administration with documentation issues |
| QMA 2 | Qualified Medication Aide | Observed medication room and medication cart storage issues |
| Kitchen Manager | Interviewed regarding kitchen sanitation and dishwasher issues | |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including antibiotic stewardship, medication reconciliation, and COVID-19 immunization |
Inspection Report
Re-Inspection
Census: 69
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to investigate multiple Nursing Home Complaints and a follow-up to a COVID-19 Focused Infection Control Survey.
Complaint Details
The visit addressed complaints IN00417850, IN00416781, IN00415518, IN00415026, and others. All complaints were corrected as noted in the report.
Findings
The facility was found to be in compliance with relevant regulations regarding the complaints investigated, with all cited complaints corrected and unrelated deficiencies also corrected.
Report Facts
Census Bed Type - SNF/NF: 63
Census Bed Type - Residential: 6
Total Census: 69
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 56
Inspection Report
Re-Inspection
Census: 69
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the investigation of multiple Nursing Home Complaints and a COVID-19 Focused Infection Control Survey, to verify correction of previously cited deficiencies.
Complaint Details
The visit was related to investigations of Nursing Home Complaints IN00419530, IN00419736, IN00420807, IN00421147, IN00417850, IN00416781, IN00415518, and IN00415026. All complaints were corrected.
Findings
Hanover Nursing Center was found to be in compliance with relevant regulations regarding the PSR to unrelated deficiencies cited during the investigations of multiple complaints. All complaints and unrelated deficiencies were corrected.
Report Facts
Census SNF/NF: 63
Census Residential: 6
Total Census: 69
Census Medicare: 6
Census Medicaid: 56
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 3
Date: Nov 20, 2023
Visit Reason
This visit was conducted for the investigation of multiple nursing home complaints (IN00419530, IN00419736, IN00420807, IN00421147) and residential complaints (IN00418288, IN00418707).
Complaint Details
The investigation included complaints IN00419530, IN00419736, IN00420807, IN00421147, IN00418288, and IN00418707. No deficiencies related to the allegations in these complaints were cited.
Findings
No deficiencies were cited related to the complaints investigated. However, unrelated deficiencies were cited including failure to accurately inventory residents' personal property for 2 of 15 residents, failure to provide behavioral health services and monitoring for 3 of 15 residents, and failure to complete ongoing monitoring documentation for residents on specialized monitoring.
Deficiencies (3)
Facility failed to accurately inventory residents' personal property for 2 of 15 residents reviewed.
Facility failed to provide behavioral health services for a resident's psychological needs and to complete ongoing monitoring for residents with behaviors for 3 of 15 residents reviewed.
Facility failed to document 15-minute monitoring for residents on specialized monitoring for multiple dates and times.
Report Facts
Residents reviewed for personal property: 15
Residents reviewed for behavioral health: 15
Residents on specialized monitoring: 2
Census: 76
Residential Census: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stefanie Jenkins | Administrator | Signed report and provided Resident Admission Agreement |
| QMA 8 | Qualified Medication Aide | Interviewed regarding Resident F's personal property inventory |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding Resident F's personal property inventory |
| Medical Records staff | Interviewed regarding missing inventory sheet for Resident G | |
| SSD | Social Service Director | Interviewed regarding behavioral health services and monitoring for Resident J |
| Psychologist | Interviewed regarding Resident J's behavioral health services | |
| Psychiatric NP | Nurse Practitioner | Interviewed regarding psychiatric services for Resident J |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding 15-minute monitoring documentation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 78
Deficiencies: 9
Date: Sep 27, 2023
Visit Reason
This visit was for the Investigation of Complaints IN00417850, IN00416781, IN00415518, and IN00415026. This visit included a COVID-19 Focused Infection Control Survey.
Complaint Details
This visit was triggered by complaints IN00417850, IN00416781, IN00415518, and IN00415026. Multiple federal and state deficiencies were cited related to these complaints including visitation rights, abuse prevention, activities programming, accident hazards, staffing, behavioral health services, food service, infection control, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to accommodate visitation rights, failure to prevent resident-to-resident sexual abuse, inadequate individualized activities programming, insufficient supervision and staffing, failure to maintain safe and sanitary environment, and failure to follow infection control guidelines related to COVID-19 isolation and precautions.
Deficiencies (9)
Failed to accommodate a resident receiving familial visitors late at night for 16 of 71 residents reviewed for visitation.
Failed to ensure resident to resident abuse did not occur related to sexual abuse resulting in a severely cognitive resident and a cognitive resident found in an unsupervised sexual situation.
Failed to develop and implement individualized activities programming to meet individual resident needs for 2 of 3 specialized resident units reviewed for activities.
Failed to ensure that the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents.
Failed to have sufficient nursing staff with appropriate competencies and skills to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for a resident with aggressive and sexually inappropriate behaviors.
Failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature for residents on Wing 2.
Failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including failure to follow COVID-19 isolation and cleaning protocols.
Failed to maintain a sanitary and safe environment related to wet floors, missing privacy curtains, gouged wall with exposed wires, broken security door, flies around food, and damaged bedside tables on Wing 2.
Report Facts
Residents affected by visitation restriction: 16
Residents reviewed for visitation: 71
Residents affected by sexual abuse incident: 2
Residents on Huntington's unit: 26
Residents on Dementia unit: 16
Residents requiring feeding assistance: 14
Residents on isolation for COVID-19: 16
Residents tested positive for COVID-19: 14
Residents on Wing 1: 16
Residents on Wing 2: 26
Residents on Wing 3: 29
Staffing levels on Wing 2 night shift: 2
Residents with behavior incidents: 1
Dates of behavior incidents for Resident D: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marlene Powell | Regional Director of Operations | Signed the report on 10/23/2023. |
| LPN 4 | Interviewed regarding staffing and resident supervision on Huntington's unit. | |
| CNA 2 | Interviewed regarding resident sexual abuse incident and staffing. | |
| CNA 3 | Interviewed regarding resident sexual abuse incident and staffing. | |
| RN 7 | Interviewed regarding staffing, meal service, and infection control. | |
| Housekeeper 11 | Interviewed regarding cleaning practices and infection control. | |
| LPN 12 | Interviewed regarding staffing and infection control. | |
| Activity Director | Interviewed regarding activities programming and staffing. | |
| SSD (Social Service Director) | Interviewed regarding behavior management and abuse prevention. | |
| BOM (Business Office Manager) | Observed cleaning and involved in resident care. |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Aug 8, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414603 and IN00413897.
Complaint Details
Complaint IN00414603 and Complaint IN00413897 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00414603 and IN00413897 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 74
Census Bed Type - Residential: 8
Total Census: 82
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 64
Census Payor Type - Other: 3
Total Census Payor Type: 74
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408985 at Hanover Nursing Center.
Complaint Details
Complaint IN00408985 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
Census SNF/NF: 66
Census Residential: 9
Total Census: 75
Census Payor Medicare: 6
Census Payor Medicaid: 59
Census Payor Other: 1
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: May 16, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00408002, IN00406770, and IN00406314 at Hanover Nursing Center.
Complaint Details
Complaints IN00408002, IN00406770, and IN00406314 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations were cited for any of the three complaints. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of complaints.
Report Facts
Census Bed Type - SNF/NF: 69
Census Bed Type - Residential: 9
Census Total: 78
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 1
Census Payor Type Total: 69
Inspection Report
Follow-Up
Census: 68
Capacity: 125
Deficiencies: 0
Date: Apr 27, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 03/08/23.
Findings
At this PSR, Hanover Nursing Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 125
Census: 68
Inspection Report
Follow-Up
Census: 68
Capacity: 77
Deficiencies: 0
Date: Apr 17, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) to Investigation of Complaint IN00403163, conducted in conjunction with the PSR to the Recertification and State Licensure Survey completed on February 27, 2023.
Complaint Details
Complaint IN00403163 was investigated and found to be corrected.
Findings
Hanover Nursing Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaint IN00403163.
Report Facts
Census SNF/NF: 68
Census Residential: 9
Total Capacity: 77
Census Medicare: 3
Census Medicaid: 64
Census Other: 1
Inspection Report
Re-Inspection
Census: 68
Capacity: 77
Deficiencies: 0
Date: Apr 17, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on February 27, 2023, including a PSR to the State Residential Licensure Survey and a PSR to Investigation of Complaint IN00403163.
Complaint Details
Complaint IN00403163 was investigated and found to be corrected.
Findings
Hanover Nursing Center 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. Complaint IN00403163 was corrected.
Report Facts
Census SNF/NF: 68
Census Residential: 9
Total Capacity: 77
Census Medicare: 3
Census Medicaid: 64
Census Other Payor: 1
Inspection Report
Complaint Investigation
Census: 67
Capacity: 76
Deficiencies: 0
Date: Apr 4, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404773 and IN00404643.
Complaint Details
Investigation of complaints IN00404773 and IN00404643 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00404773 and IN00404643 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF: 67
Census Residential: 9
Total Capacity: 76
Census Medicare: 3
Census Medicaid: 63
Census Other Payor: 1
Total Census: 67
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Date: Mar 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00403163 regarding allegations of inadequate assistance with activities of daily living, specifically incontinence care.
Complaint Details
Complaint IN00403163 was substantiated with a federal/state deficiency cited at F677 related to allegations that a CNA threw a brief at Resident B and told him to change himself, failing to provide appropriate incontinence care.
Findings
The facility failed to ensure that a resident requiring extensive assistance with ADLs received appropriate incontinence care. A CNA was found to have thrown a brief at a resident and told him to change himself, which was confirmed by multiple interviews and incident reports. The CNA was suspended and terminated, and corrective actions including staff re-education and monitoring were implemented.
Deficiencies (1)
Failure to ensure a resident who required extensive assistance for ADLs received appropriate incontinence care.
Report Facts
Census Bed Type - SNF/NF: 70
Census Bed Type - Residential: 9
Total Census: 79
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Mace | Consultant | Signed the report |
Inspection Report
Routine
Census: 66
Capacity: 125
Deficiencies: 16
Date: Mar 8, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare/Medicaid participation requirements and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code, and other regulatory standards including deficiencies in emergency plan exercises, generator maintenance, fire safety equipment, smoke barrier doors, and fire drills.
Deficiencies (16)
Failed to conduct required community-based emergency preparedness exercise annually.
Failed to maintain written records of weekly generator inspections for 12 of 52 weeks and monthly load testing for 4 of 12 months.
Means of egress through 1 of 11 locked exit doors was not readily accessible; code to open door was not posted.
Exit across from small dining room lacked exterior lighting.
Cooktop stove in Activity Room was not deactivated when not in use.
Incomplete documentation for monthly testing of battery-operated smoke alarms in resident rooms for 3 months.
Failed to document weekly inspection of dry sprinkler system gauges and monthly inspection of sprinkler control valves.
Ceiling openings and holes in sprinklered smoke compartments were not properly fire stopped.
One portable fire extinguisher lacked documented annual maintenance; monthly inspections of all extinguishers not completed; one extinguisher was obstructed.
One fire extinguisher had pressure gauge reading outside acceptable range.
Dishwashing room door was propped open with a bucket, preventing proper closing of smoke barrier door.
Set of smoke barrier doors near Director of Nursing office did not close completely, leaving a one inch gap.
Fuel-fired water heater lacked current inspection certificate.
Electrical receptacle in Wing 2 Supply Storage Room lacked cover plate and exposed wiring.
Fire drill documentation incomplete for 1 of 3 shifts during 3 of 4 quarters; 5 of 13 fire drills lacked staff signatures.
Portable space heater was used in Medical Records room contrary to facility policy.
Report Facts
Certified beds: 125
Current census: 66
Deficiency count: 15
Generator weekly inspections missing: 12
Generator monthly load tests missing: 4
Fire drills missing documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Mace | Consultant | Signed the report. |
Inspection Report
Renewal
Census: 8
Deficiencies: 20
Date: Feb 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey. This visit included the Investigation of Complaints IN00401987, IN00401922, IN00401322, IN00401375 and a State Residential Licensure Survey.
Complaint Details
Complaint IN00401987 - No deficiencies related to the allegations are cited. Complaint IN00401922 - Federal/State deficiency related to the allegation is cited at F584. Complaint IN00401322 - No deficiencies related to the allegations are cited. Complaint IN00401375 - No deficiencies related to the allegations are cited.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, notification of changes, safe environment maintenance, accuracy of assessments, comprehensive care planning, pressure ulcer treatment, incontinence management, timely laboratory services, nutrition and hydration, antibiotic stewardship, fire drills, medication administration, and psychotropic medication monitoring.
Deficiencies (20)
Failed to treat residents with dignity related to residents sitting on the floor with pants down and staff not assisting promptly.
Failed to notify physician of blood glucose levels that were out of range for 1 of 22 residents reviewed.
Failed to maintain a homelike setting for 1 of 24 resident rooms reviewed due to damaged walls.
Failed to accurately complete MDS assessments related to falls for 2 of 19 residents reviewed.
Failed to develop care plans for residents receiving hospice services, dialysis treatments, and psychotropic medications for 3 of 20 residents reviewed.
Failed to monitor and administer treatments for a pressure ulcer for 1 of 3 residents reviewed.
Failed to obtain a urinalysis in a timely manner for 1 of 1 residents reviewed for UTI.
Failed to adequately monitor a resident with significant weight loss for 1 of 3 residents reviewed for nutrition.
Failed to appropriately manage a resident's respiratory needs related to maintaining oxygen equipment for 1 of 1 resident reviewed.
Failed to monitor a dialysis access site for 1 of 1 resident reviewed for dialysis.
Failed to follow physician's orders related to medication administration parameters for cardiac medications and monitor for adverse side effects of an anticoagulant medication for 1 of 5 residents reviewed for unnecessary medications.
Failed to adequately monitor residents for adverse side effects of psychotropic medications for 4 of 5 residents reviewed for unnecessary medications.
Failed to store medications appropriately related to insulin pens for 2 of 4 medication carts reviewed, failed to return medications to the pharmacy in a timely manner for 1 of 2 medication rooms reviewed, and failed to lock medication carts for 2 of 8 observations.
Failed to schedule an appointment for a biopsy and failed to follow physician orders for laboratory services for 2 of 22 residents reviewed for laboratory services.
Failed to provide palatable meals and provide menus for 3 of 24 residents reviewed for food.
Failed to implement antibiotic stewardship protocol for antibiotic use for 2 of 2 months reviewed.
Failed to regularly conduct fire drills for 3 of the 12 months reviewed and failed to contact the fire department at least twice a year.
Failed to ensure residents that self-administered medications were assessed for self-medication administration for 3 of 7 residents reviewed for medication administration.
Failed to label preset cups of medications for 7 of 7 residents and had an unlabeled cup of non-resident pills observed in the medication cart during medication administration.
Failed to dispose of medications appropriately for 1 of 2 medication administration observations.
Report Facts
Survey dates: 5
Census: 79
Deficiencies cited: 18
Deficiencies cited: 11
Weight loss: 10.43
Fire drills missing: 3
Fire department contacts: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Mace | Consultant | Signed the report |
| LPN 2 | Licensed Practical Nurse | Provided information on dialysis access site monitoring, oxygen tubing changes, medication administration, and blood pressure parameters |
| LPN 3 | Licensed Practical Nurse | Provided information on resident dignity, notification of changes, and lab results |
| QMA 7 | Qualified Medication Assistant | Provided information on resident dignity and medication side effect monitoring |
| ADON | Assistant Director of Nursing | Provided information on liver biopsy scheduling, medication disposal, and antibiotic stewardship |
| AIT | Administrator in Training | Provided information on fire drills, lab orders, and dementia special care unit form |
| DON | Director of Nursing | Observed medication administration and disposal practices |
Inspection Report
Re-Inspection
Census: 72
Capacity: 80
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00394773 and IN00391313 completed on November 30, 2022, and in conjunction with the PSR to the Investigation of Complaint IN00399584 completed on January 19, 2023.
Complaint Details
This visit was related to the investigation of complaints IN00394773, IN00391313, and IN00399584. All complaints were corrected.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSRs for the investigations of the complaints. All three complaints were corrected.
Report Facts
Census SNF/NF beds: 72
Census Residential beds: 8
Total Census: 72
Total Capacity: 80
Medicare Census: 5
Medicaid Census: 66
Other Payor Census: 1
Inspection Report
Re-Inspection
Census: 80
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00399584 completed on January 19, 2023, and was conducted in conjunction with PSRs to Complaints IN00394773 and IN00391313 completed on November 30, 2022.
Complaint Details
This visit was related to complaint investigations IN00399584, IN00394773, and IN00391313. All complaints were found to be corrected.
Findings
Hanover Nursing Center 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 Investigation of Complaint IN00399584. All three complaints were corrected.
Report Facts
Census Bed Type - SNF/NF: 72
Census Bed Type - Residential: 8
Census Bed Type - Total: 80
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 1
Census Payor Type - Total: 72
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
This visit was for the investigation of five complaints (IN00399584, IN00398804, IN00397827, IN00397179, and IN00397047) regarding the facility's compliance with regulatory requirements.
Complaint Details
Complaint IN00399584 was substantiated with deficiencies cited at F755 related to pharmacy services. Complaints IN00398804, IN00397179, and IN00397047 were substantiated with no deficiencies cited. Complaint IN00397827 was unsubstantiated due to lack of evidence.
Findings
The investigation substantiated some complaints, with federal/state deficiencies cited related to pharmacy services, specifically the failure to ensure proper disposal of controlled medications requiring two staff signatures. Other complaints were substantiated but had no deficiencies cited, and one complaint was unsubstantiated due to lack of evidence.
Deficiencies (1)
The facility failed to ensure the disposal of controlled medications were appropriately signed off by two staff members for 2 of 3 residents reviewed for pharmacy services.
Report Facts
Census Bed Type - SNF/NF: 70
Census Bed Type - Residential: 9
Total Census: 79
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 1
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah McKenzie | AIT/HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Claire Matheny | AIT/HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Renewal
Deficiencies: 1
Date: Dec 13, 2022
Visit Reason
This was an offsite Licensure Investigation Survey conducted to review the facility's compliance with license renewal requirements, specifically to determine if the renewal application was submitted timely prior to license expiration.
Findings
The facility failed to submit the renewal application at least 45 days prior to the expiration of their license, as the renewal application and payment were postmarked after the license expiration date. The administrator was re-educated on timely submission and ongoing compliance monitoring was planned.
Deficiencies (1)
Facility failed to ensure timely renewal of license to operate as a residential care facility before license expiration on 10/31/22.
Report Facts
Days late for renewal application: 4
Days required prior to expiration for renewal application: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah McKenzie | AIT/HFA | Signed as Laboratory Director's or Provider/Supplier Representative |
| Claire Matheny | AIT/HFA | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 4
Date: Nov 30, 2022
Visit Reason
This visit was for the investigation of complaints IN00394747, IN00394773, and IN00391313.
Complaint Details
Complaint IN00394747 - Substantiated with no deficiencies cited. Complaint IN00394773 - Substantiated with deficiencies cited at F921 and F838. Complaint IN00391313 - Substantiated with deficiencies cited at F684 and F692.
Findings
The facility was found to have deficiencies related to quality of care, nutrition/hydration status maintenance, facility assessment, and environmental safety. Specific findings included failure to prevent dehydration and weight loss resulting in hospitalization and death of one resident, failure to maintain acceptable hydration parameters for three residents, incomplete facility assessment regarding staffing, and unsafe laundry room conditions due to standing water from washing machines.
Deficiencies (4)
Failed to identify, monitor, and provide needed care and services to prevent dehydration, weight loss, and physician notification resulting in hospitalization for 1 of 9 residents reviewed for Quality of Care (Resident B).
Failed to maintain acceptable parameters of nutritional fluid status for 3 of 4 residents reviewed for hydration (Residents C, D, and E).
Failed to complete the facility assessment to determine staffing levels and competencies required to provide necessary care and services to meet each resident's needs, potentially affecting all residents.
Failed to provide a safe, functional, and sanitary environment due to standing water from the washing machines when draining, potentially affecting all residents.
Report Facts
Census: 79
Fluid intake: 600
Fluid intake: 480
Fluid intake: 1080
Fluid intake: 480
Fluid intake: 740
Fluid intake: 960
Fluid intake: 900
Weight: 154
Weight: 143
Weight: 138
Weight: 131
Fluid intake: 480
Fluid intake: 600
Fluid intake: 680
Fluid intake: 600
Fluid intake: 200
Weight: 134
Fluid intake: 0
Fluid intake: 480
Fluid intake: 680
Weight: 144
Fluid intake: 960
Fluid intake: 480
Fluid intake: 440
Weight: 243
Staffing: 6
Staffing: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah McKenzie | AIT/HFA | Signed report as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 20, 2022
Visit Reason
The inspection was a paper compliance review related to Complaint Investigation IN00382302 completed on August 9, 2022.
Complaint Details
Complaint Investigation IN00382302 was completed on August 9, 2022, and the facility was found to be in compliance.
Findings
Hanover Nursing Center 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 to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388483 at Hanover Nursing Center.
Complaint Details
Complaint IN00388483 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint was found to be unsubstantiated due to lack of evidence. The facility was in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Bed Type: 68
Census Bed Type: 7
Total Census: 75
Census Payor Type: 21
Census Payor Type: 46
Census Payor Type: 1
Total Census Payor: 68
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 1
Date: Aug 9, 2022
Visit Reason
The visit was conducted for the investigation of Complaint IN00382302, which was substantiated with a related federal/state deficiency cited.
Complaint Details
Complaint IN00382302 was substantiated. The deficiency related to allegations of inadequate supervision of a resident at risk for choking during meals.
Findings
The facility failed to ensure adequate supervision for a resident at risk for choking during meals when not positioned in a specialized chair, violating accident hazard prevention requirements.
Deficiencies (1)
Failure to ensure adequate supervision for a resident at risk for choking during meals when not up in a specialized chair.
Report Facts
Census SNF/NF beds: 72
Census Residential beds: 7
Total Census: 79
Census Payor Medicare: 29
Census Payor Medicaid: 42
Census Payor Other: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide (CNA) 2 | Observed delivering meal tray and not following care plan for resident supervision | |
| RN 3 | Interviewed regarding care plan and supervision monitoring | |
| Speech Therapist 1 | Provided expert opinion on resident's risk for choking and positioning |
Inspection Report
Follow-Up
Census: 72
Capacity: 125
Deficiencies: 0
Date: Aug 1, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 06/01/22.
Findings
At this PSR survey, Hanover Nursing Center 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 except for the detached emergency generator building.
Report
Aug 29, 2025
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Jun 27, 2025
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Sep 4, 2024
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Jul 18, 2024
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Jan 10, 2024
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Jan 10, 2024
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Nov 20, 2023
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Sep 27, 2023
Report
Sep 27, 2023
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