Indian Hills Manor

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record review, the facility failed to ensure outdated food items were not available for use, items were labeled correctly, and failed to perform proper hand hygiene and change gloves while preparing food to prevent the potential for cross contamination and food-borne illness. The facility identified a census of 32. This had the potential to affect all residents who ate out of the kitchen.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii) Based on record review and interview, the facility failed to ensure 1 of 5 sampled nurse aides completed 12 hours of in-service educations and 4 hours of dementia training as required. Findings Are: A record review of an untitled facility-provided document revealed a list of current employees of the facility with name, department, job title, and hire dates. The document also revealed Nurse Aide - A (NA-A) was hired on 2/1/2022. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview, the facility failed to ensure the consultant pharmacist completed a Medication Regimen Review every month as required for 3 of 5 sampled residents (Residents 2, 6, and 25 ). The facility identified a census of 32. Findings Are: Record review of a facility policy dated 11/2022 labeled Medication Regimen Review revealed the following information: - The requirements associated with the Medication Regimen Review (MRR) apply to all residents, whether short or long stay - The pharmacist shall document, either manually or electronically, that each medication regimen review has been completed - Each MRR shall be signed by the pharmacist - The consultant pharmacist shall schedule at least one monthly visit to the facility and shall allow for sufficient time to complete all required activities. A. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(A)Based on record review and interview, the facility failed to ensure 3 of 5 sampled residents (Residents 14, 21, 25) had received or declined influenza and pneumococcal immunizations as required. The facility identified a census of 32 residents. A. Record review of Resident 14's face sheet revealed they were admitted to the facility on [DATE]. Record review of Resident 14's Electric Medical Record (EMR) revealed no evidence of Resident 14 receiving or refusing the Pneumococcal immunization, or being medically ineligible to receive it. B. Record review of Resident 21's face sheet revealed they were admitted to the facility on [DATE]. Record review of Resident 21's EMR revealed no evidence of Resident 21 receiving or refusing the pneumococcal immunization, or being medically ineligible to receive it. C. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(A)Based on record review and interview, the facility failed to ensure 3 of 5 sampled residents (Residents 14, 21, 25) had received or declined COVID-19 (coronavirus disease 2019, a highly contagious respiratory illness caused by the SARS-CoV-2 virus) immunizations as required. The facility identified a census of 32 residents. A. Record review of Resident 14's face sheet revealed they were admitted to the facility on [DATE]. Record review of Resident 14's Electric Medical Record (EMR) revealed no evidence of Resident 14 receiving or refusing the COVID-19 immunization, or being medically ineligible to receive it. B. Record review of Resident 21's face sheet revealed they were admitted to the facility on [DATE]. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F) Based on record review, observation, and interview, the facility failed to ensure 1 (Resident 21) of 2 sampled resident's care plan accurately reflected their physical mobility and psychosocial care, and 1 (Resident 25) of 2 sampled resident's care plan accurately reflected their physical mobility and activities of daily living (ADLs). The facility identified a census of 32 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to ensure oxygen concentrators were turned off when not in use for 2 (Residents 30 and 3) of 5 sampled residents to prevent the potential for accidents. The facility identified a census of 32 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 (J)(iii)Based on observation, record review, and interview, the facility failed to ensure 2 of 2 sampled residents (Residents 14 and 22) received hydration to meet their daily needs. The facility identified a census of 32 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation, interview, record review, the facility failed to ensure oxygen tubing was maintained in a clean and sanitary manner, changed and dated according to physician orders and facility policy to prevent the potential for infection for 1 (Resident 30) of 5 sampled residents. The facility identified a census of 32 residents. Findings Are: Record review of facility policy titled Oxygen Usage Policy with revision date of January 2022 revealed under Care of Equipment section, item number 5 titled oxygen tubing, the policy read to change tubing and mask/cannula at least every two weeks and change tubing if visibly soiled or if cannula/mask becomes contaminated. Record review of Resident 30's physician order dated 7/9/2025 reveals the resident is to be administered oxygen at 2 liters per minute to maintain oxygen saturation above 90%. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 of 5 sampled residents' (Resident 14) medication regimens were free from unnecessary antibiotics. The facility identified a census of 32 residents. Record review of Resident 14's face sheet revealed they were admitted to the facility on [DATE] and diagnosed with Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), constipation (a problem with passing stool infrequently or because it is hard), moderate intellectual disabilities (limitation in intellectual function, understanding and use of language, and adaptive behavior), chronic kidney disease, and history of urinary tract infections. [...]

Inspectors wroteLicensure 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). [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D8b Based on observations, record review and interview; the facility failed to implement, evaluate and/or revise nutritional interventions to address ongoing and significant weight loss for 3 (Residents 3, 4 and 27) of 4 sampled residents. The facility census was 34.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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; [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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.

Inspectors wroteBased 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.

Inspectors wroteLicensure 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.