Indian Hills Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report an incident of resident-to-resident abuse to the State Agency within 2 hours, and failed to submit an investigation report to the State Agency within 5 working days of the incident. This affected 2 (Residents 1 and 2) of 2 sampled residents. The facility identified a census of 38. A record review of Resident 1's face sheet revealed Resident 1 was admitted on [DATE] with unspecified dementia (a decline in cognitive function affecting memory, thinking, and behavior), weight loss, unsteadiness on feet, and type 2 diabetes mellitus (a metabolic disorder where the body does not regulate blood sugar effectively).A record review of Resident 2's face sheet revealed Resident 2 was admitted on [DATE] with chronic obstructive pulmonary disease (a progressive lung disease that restricts breathing, often caused by smoking), pneumonia (an infection that inflames the air sacs in the lungs), bladder dysfunction,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to ensure that 4 of 5 sampled employees had completed at least 12 hours of ongoing training for the year as required. This had the potential to affect all residents who reside within the facility. The facility identified a census of 27. Findings are: A record review the facility's Facility Assessment Tool with a date of 2/26/2025 revealed all training will be completed at least upon orientation, annually, and as needed of at least 12 hours per year. Topics of training included dementia, abuse/neglect, effective communication, resident's rights, infection control, culture changes, and orthopedic special care. A record review of an undated staff list provided by the facility revealed the following: - Medication Aide (MA) - D was hired on 8/19/2010. - Nurse Aide (NA) - A was hired on 7/1/2022. - MA-G was hired on 4/21/2013. - MA-F was hired on 5/3/2022. A record review of MA-D's Training Hours from 8/19/2023-8/19/2024 revealed MA-D had a total of 0.5 hours of ongoing training.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference 12-006.18 Licensure Reference 12-006.09 (D)2 Based on observations, record review, and interview, the facility failed to implement a water management program as required to monitor and prevent the potential for legionella and other waterborne pathogens. This had the potential to affect all residents that resided within the facility. The facility also failed to perform hand hygiene as required during wound care for 1 (Resident 2) of 1 sampled resident. The facility identified a census of 27. Findings are: A. A record review of a facility policy titled, Water system management program prevention plan for legionella, and dated 2022, revealed in the policy explanation and compliance guidelines section: 2. The maintenance director maintains documentation that describes the facility's water system. 6. Control measures will be applied to address potential hazards at each control point. The measures shall be specified in the water management program action plan. The Sample Water System Surveillance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.04(B)(i) Based on record reviews and interview, the facility failed to ensure 5 of 5 sampled employees had completed initial orientation training within 2 weeks after beginning employment that included resident rights and emergency procedures as required. This had the potential to affect all residents who resident within the facility. The facility identified a census of 27. Findings are: A record review the facility's Facility Assessment Tool with a date of 2/26/2025 revealed training will be completed at orientation, annually, and as needed. Trainings will include effective communication, resident right's abuse/neglect, infection control, and culture change. A record review of an undated staff list provided by the facility revealed the following: - Cook-H was hired on 11/7/2024. - Dietary Aide (DA) - I was hired on 1/7/2025. - The Director of Nursing (DON) was hired on 2/16/2025. - Nurse Aide (NA) - B was hired on 1/6/2025. - NA-C was hired on 12/2/2024. A record review of Cook-H's personnel file documents provided by the facility revealed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to ensure that 4 of 5 sampled employees had completed at least 12 hours of ongoing training in the year which included dementia management training and resident abuse prevention training. This had the potential to affect all residents who reside within the facility. The facility identified a census of 27. Findings are: A record review the facility's Facility Assessment Tool with a date of 2/26/2025 revealed all training will be completed at least upon orientation, annually, and as needed of at least 12 hours per year. Topics of training included dementia, abuse/neglect, effective communication, resident's rights, infection control, culture changes, and orthopedic special care. A record review of an undated staff list provided by the facility revealed the following: - Medication Aide (MA) - D was hired on 8/19/2010. - Nurse Aide (NA) - A was hired on 7/1/2022. - MA-G was hired on 4/21/2013. - MA-F was hired on 5/3/2022. A record review of MA-D's Training Hours from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to protect the private health information of 3 (Residents 9, 23, and 32) of 4 sampled residents. The facility identified a census of 27. Findings are: A continuous observation on 2/27/25 from 7:26 AM to 8:00 AM revealed Registered Nurse (RN-J) administering medications in the dining room using a laptop computer mounted on a mobile medication cart. The observation revealed RN-J preparing medications for Resident 32. RN-J took the prepared medications to Resident 32's table, leaving the computer screen open with Resident 32's private health information visible while they walked to the resident and administered the medications. RN-J then returned to the medication cart, marked the medications as administered in the computer and proceeded to the next resident. The observation revealed RN-J preparing medications for Resident 9. RN-J took the prepared medications to Resident 9's table, leaving the computer screen open with Resident 9's private health information visible while they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(i) Based on interview and record review the facility failed to develop and implement a baseline care plan within 48 hours of admission for 3 (Resident 35, 27, and 23) of 4 sampled residents. The facility identified a census of 27. The findings are: A record review of a Baseline Care Plan Policy dated 4/23/2019 revealed the baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: i. Initial goals based on admission orders ii. Physician orders iii. Dietary orders iv. Therapy services v. Social Services vi. PASARR recommendations, if applicable. A. A record review of an admission face sheet for Resident 35 revealed an admission date of 1/30/25. Resident 35 was admitted to the facility for Palliative Care (care that is focused on symptom control, pain relief, and quality of life). A record review of an admission facesheet for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.09(H)(vi)(3)(g) Based on interview and record review the facility failed to ensure that monitoring during the course of their acute illness was documented for 3 (Resident 3, 8, and 18) of 3 sampled residents . The facility identified a census of 27. The findings are: A record review of a Change of Condition Policy dated 3/2019 revealed on page 4 (B.)- The Nurse will record information relative to changes in the residents condition or status in the resident's medical record. The residents' condition is assessed and reported in a timely manner either verbally or written if the resident experiences signs and symptoms of infection. A. A record review of Resident 18's admission face sheet revealed an admission date of 3/24/22. A record review of Resident 18's pertinent diagnoses include: 1. Unspecified dementia (a condition where cognitive decline and memory loss occur, but the specific underlying cause cannot be determined). 2. Ventricular Tachycardia (a fast, abnormal heart rhythm). 3. Cardiomyopathy (disorder that affects the heart muscles ability to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.09(D) Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) accurately reflected active diagnoses for 1 (Resident 3) of 12 sampled residents. The facility identified a census of 27. Findings are: A record review of a facility policy, MDS Policy with a revision date of March 2019 revealed a the purpose of the policy was to ensure the timeliness and accuracy of all MDS' by ensuring the facility staff followed the guidelines laid out in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities.) A record review of the RAI Manual with an effective date of 10/1/2023 revealed the following in regarding to Section I: Active Diagnoses under steps for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.09(H)(i)(3) Based on record reviews and interviews, the facility failed to provide bathing services during isolation precautions for 1 (Resident 3) of 1 sampled resident. The facility identified a census of 27. Findings are: A record review of a facility policy, ADL Assistance Provided Per Care Plan with a revised date of 9/2022 revealed bathing and showering would be provided as needed based upon the resident's desires, assessment, care plan, and ADL (Activities of Daily Living) assistance deemed necessary. A record review of an admission Record indicated the facility admitted Resident 3 on 1/11/2022 with a diagnosis of Dementia (a progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior.) A record review of Resident 3's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.06B Licensure Reference Number 175 NAC 12-006.05(7) Based on record review and interivews; the facility failed to resolve ongoing grievance concerns and failed to assure residents were able to voice concerns without retaliation by the staff. This had the potential to affect all residents. The facility census was 34. Findings Are: A. Record review of the facility policy Grievance/ Concern with a revision date of 3/2019 revealed the purpose of the policy was to ensure the residents had the right to voice grievances without discrimination or reprisal and without fear of discrimination or reprisal. The policy further revealed that grievances/concerns reported during resident and/or family council meetings were to be transferred to a grievance form and given to the Grievance Official or Administrator. In addition, all grievances/concerns were to be logged and completed by Social Services Director (SSD) or assigned to an appropriate designated person for investigation. A written report of the investigation and recommended action(s) were to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number: 175 NAC 12-006.04D2a Based on record review and interview; the facility failed to ensure the Dietary Manager (DM) had the credentialing to meet the requirements for the position. This had the potential to affect all residents who consumed food from the kitchen. The facility census was 34 with a total sample size of 19. Findings are: Review of the facility Job Description for the role of Dietary Service Director dated 7/1/2018 revealed necessary qualifications included the completion of a Dietary Manager certification course. During an interview on 4/9/24 at 10:08 AM, the [NAME] President of Operations and the facility Administrator confirmed the current Dietary Manager did not have the required training to meet the qualification for the DM position.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review and interview; the facility staff failed to: 1) utilize handwashing and gloving techniques; and 2) store, prepare and serve food in a manner to prevent the potential for cross contamination and/or food borne illness. These practices had the potential to affect all residents who were served meals from the kitchen. The facility identified a census of 34. Findings are: A. Review of the undated facility policy Date Marking for Food Safety revealed the following regarding the system used to ensure the safety of ready-to-eat food items: -all food to be clearly marked to indicate the date by which the food was to be consumed or discarded. -the individual opening or preparing a food was to be responsible for date marking the food at the time the food was opened or prepared. -the marking system was to consist of the day/date of opening and the day/date the item was to be discarded. -the discard day/date was not to exceed the manufacture's use-by date, or 4 days, whichever was the earliest. The date when food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.07C Based on record review and interview; the facility failed to assure the facility had an effective quality assurance and performance improvement program. This had the potential to affect all residents who resided within the facility. The facility census was 34. The findings are: A record review of a facility provided policy titled QAA (Quality Assurance and Assessment) and QAPI (Quality Assurance and Performance Improvement) Policy and Procedure with a revision date of March 2023 revealed in the Policy Explanation and Compliance Guidelines that the QAA committee was to consist at a minimum of the Director of Nursing (DON), Medical Director (MD), Infection Preventionist (IP), and three other members of the facility staff. The program was to be ongoing, comprehensive and would address the full range of care and services provided by the facility. The policy stated the facility would develop and implement appropriate plans of action to correct identified quality deficiencies and that they would meet at least quarterly and as needed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview; the facility failed to: 1) utilize the required Personal Protective Equipment (PPE-can include items such as gowns, gloves, masks, goggles, face shields, and foot coverings) when performing wound care for Resident 13 who was on Enhanced Barrier Precautions; 2) complete hand hygiene (hand washing using soap and water or an alcohol based hand rub) and gloving when completing a blood glucose test for Resident 25 and then cleaning/disinfecting the glucose monitor in accordance with manufacturer's recommendations; 3) perform hand hygiene during the distribution of laundry for Residents 5, 8, 9, 12, 14, 15, 19, 25 and 26; and 4) implement measures to prevent the growth of Legionella (severe type of pneumonia/lung infection caused by bacteria which can be found in water) and/or waterborne pathogens in the facility. These practices had the potential to affect all facility residents. The total sample size was 19 and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.04B2a Based on interviews and record review; the facility failed to ensure 4 Nursing Assistants (NA) (NA-M, NA-N, NA-O, NA-P) had at least 12 hours of continuing education in 2023, including Dementia and infection control training of 5 staff reviewed. The facility identified a census of 34. The findings are: A record review of staff education records revealed the following: - NA-M had a total of 0.5 hours of continuing education for 2023 and did not have Dementia or infection control training - NA-N had a total of 4.25 hours of continuing education for 2023 and did not have Dementia training - NA-O had a total of 7.10 hours of continuing education for 2023 - NA-P had a total of 5.15 hours of 12 hours of continuing education for 2023 An interview on 4/8/2024 at 4:07 PM with the Administrator confirmed the staff did not have the required continuing education. A record review of a facility policy Staff Training, Retention of Records, Including CNA, Programing Policy and Procedure with an effective date of October 2022, revealed the facility will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D1c Based on observations, record review and interview; the facility failed to provide timely repositioning and feeding assistance for Residents 4, 15 and 27 and toileting assistance/incontinence management for Residents 4 and 15 who all required assistance with activities of daily living (ADLs). The sample size was 3 and the facility census was 34. Findings are: A. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/16/24 revealed diagnoses of chronic pain, anemia, chronic obstructive pulmonary disease (COPD), anxiety, depression, and dementia. In addition, the resident required supervision and/or touching assistance with eating and drinking, and was dependent with oral and toileting hygiene, dressing, bed mobility, personal hygiene, and transfers. The resident was assessed as frequently incontinent of bowel and bladder. Review of Resident 4's current, undated Care Plan revealed the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04C Based on observations, record review and interviews; the facility failed to ensure sufficient staff were available to provide Residents 3, 4 and 27 with timely feeding assistance, repositioning, and incontinence cares. The total sample size was 19 and the facility census was 34. Findings are: A. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/16/24 revealed diagnoses of chronic pain, anemia, chronic obstructive pulmonary disease (COPD), anxiety, depression, and dementia. In addition, the resident required supervision and/or touching assistance with eating and drinking, and was dependent with oral and toileting hygiene, dressing, bed mobility, personal hygiene, and transfers. The resident was assessed as frequently incontinent of bowel and bladder. Review of Resident 4's current, undated Care Plan revealed the resident had limited physical mobility and limited ability to perform ADLs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.09D7 Based on observations, interviews, and record review; the facility failed to ensure call devices were within reach for 2 (Resident 14 and Resident 23) of 2 sampled residents. The facility identified a census of 34. The findings are: A record review of the facility policy Call Light Accessibility and Timely Response Policy and Procedure with a last revised date of March 2024 revealed staff will ensure the call light is within reach of residents and secured. A. A record review of Resident 14's annual Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents), with an Assessment Reference Date (ARD) of 1/2/2024 revealed Resident 14 had a Brief Interview for Mental Status score of 5/15, which indicated Resident 14 had severe cognitive impairment. The MDS also revealed Resident 14 required max assistance for toileting, hygiene, and dressing. A record review of Resident 14's Care Plan, initiated on 9/12/2023, revealed Resident 14 was at risk for falls related to diagnoses of Dementia and Parkinson's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09B. Based on record review and interview, the facility failed to accurately assess 1 (Resident 33) of 2 sampled resident's medication usage when completing their admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool utilized to develop resident care plans). The facility census was 34. The findings are: A record review of Resident 33's admission Record revealed the resident was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus, (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A record review of Resident 33's Physician's Orders revealed an order for the nurses to monitor the resident for adverse effects from insulin and oral hypoglycemic medications each shift. Resident 33 also had medication orders for glipizide 10 milligrams (mg) twice a day (BID) and metformin 500mg BID, as well as an order for Victoza 1.8mg to be injected once a day. All of these medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interview; the facility failed to revise 1 (Resident 23) of 12 sampled residents' care plan when the resident was treated for a urinary tract infection. The facility census was 34. The Findings Are: A record review of Resident 23's admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of Unspecified Dementia, mild, with psychotic disturbance. A record review of a document scanned into Resident 23's electronic health record (EHR) titled Urine Dip Report and dated 3/26/24 revealed the resident's urine was red and hazy and that the resident had symptoms of blood in the urine and painful urination. A record review of a document scanned into Resident 23's EHR titled Urinalysis revealed a urinalysis, a physical, chemical, and microscopic examination of urine, was obtained on 3/26/24 and the culture of the urine was finalized on 3/31/24. A record review of Resident 23's Physician's Orders revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D2b Based on observations, record review, and interviews; the facility failed to implement interventions per the facility's policy and the resident's care plan for 1 (Resident 3) of 3 sampled residents to promoting the healing of their pressure ulcer. The facility census was 34. The findings are: A record review of Resident 3's admission Record revealed the resident was admitted to the facility on [DATE] with a diagnosis of complete paraplegia, which is an Injury between spinal nerves T1 and T6 that causes the hips and legs to be paralyzed and have no feeling at all. This also causes loss of bladder and bowel control. The resident had a primary diagnosis added on 9/22/2021 of a stage 4 pressure ulcer of contiguous site of back, buttock and hip. A record review of a facility provided policy Prevention of Pressure Ulcers Policy with revision date of March 2019 revealed in General Guidelines, #1. Pressure ulcers are usually formed when a resident remains in the same…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review; the facility failed to ensure Medication Regimen Reviews had been reviewed by the physician and a rationale was provided when no action was taken for 1 (Resident 14) of 5 sampled residents. The facility identified a census of 34. The findings are: A record review of an admission Record indicated the facility admitted Resident 14 on 1/17/2020 with diagnoses of Dementia, Parkinson's disease, delusional disorder, Major Depressive Disorder, anxiety, heart failure, and Chronic Obstructive Pulmonary Disease. A record review of a Consultation Report with a date of 9/24/2023 revealed the Pharmacist had conducted a comprehensive medication review, but the facility had no documentation that the physician had also completed the monthly review for Resident 14. A record review of a Consultation Report with a date of 11/15/2023 revealed the Pharmacist had concerns regarding Resident 14's citalopram and risperidone. The facility had no documentation that they physician had reviewed or responded to the concerns. An interview on 4/10/2024 at 9:30 AM with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006019D Based on record review and interview; the facility failed to ensure that PRN (as needed) orders for psychotropic (any drug capable of affecting the mind, emotions, and behavior) drugs were limited to 14 days or had a stop date or duration documented by the prescriber. In addition, the facility did not have a supporting diagnosis for use of the PRN antipsychotic for 1 (Resident 88) of 5 sampled residents. The facility census was 34. Findings are: A. Review of the facility Antipsychotic Use Policy and Procedure with a revision date of 11/22 revealed the following procedure was to be followed to ensure antipsychotic medications were only used as necessary to treat specific conditions: -prior to requesting medications for the purpose o mood, behavior, or sleep concerns the Interdisciplinary Team was to review non-medical alternatives which had been attempted and to attempt to establish root cause of behaviors. -if alternatives were attempted without success, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.