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Deficiency Records for Indian Hills Manor
A list of the most recent deficiencies for Indian Hills Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Indian Hills Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-10 | 2024-05-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-10 | 2024-05-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-04-10 | 2024-05-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-15 | 2024-05-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-04-15 | 2024-05-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-15 | 2024-05-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-04-15 | 2024-05-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-15 | 2024-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-15 | 2024-05-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-15 | 2024-05-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-04-15 | 2024-05-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-04-15 | 2024-05-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-04-15 | 2024-05-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-04-15 | 2024-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-15 | 2024-05-15 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-04-15 | 2024-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-15 | 2024-05-15 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-04-15 | 2024-05-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-06 | 2023-05-21 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-04-06 | 2023-05-21 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-04-06 | 2023-05-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-06 | 2023-05-21 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-06 | 2023-05-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-04-06 | 2023-05-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-06 | 2023-05-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-02-09 | 2022-04-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-02-09 | 2022-04-01 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-02-09 | 2022-04-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-09 | 2022-04-01 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-09 | 2022-04-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-09 | 2022-04-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-09 | 2022-04-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-09 | 2022-04-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-04-01 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-02-09 | 2022-04-01 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-07 | 2022-04-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-07 | 2022-03-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-07 | 2022-03-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-07 | 2022-03-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-07 | 2022-03-26 | N |
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