Hillside Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure medications were stored in accordance with current professional standards in four medication carts (100, 200, 300, and 400) of four observed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure informed consent was documented for psychotropic medications, as indicated, for three of three residents (#7, #25, #73) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations and interviews the facility failed to provide a clean, sanitary, and homelike environment in three units (200, 300, and 400) out of four units, affecting six resident rooms (207, 203, 201, 405, 305 and 307) and failed to ensure one laundry room out of one observed was maintained in a sanitary manner.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASARR) for three residents (#26, #25, #73) out of four residents sampled for PASARRs.

Inspectors wroteBased on observation and interview, the facility failed to ensure food, and food storage areas were maintained in a sanitary manner in the one out of one kitchen (main) and in two out of two nourishment rooms observed. During a kitchen tour conducted on 05/17/2026 at 9:24 AM, observations were made of employee food and beverages being stored in food preparation areas. Employees food was observed on a table next to the dessert cooler. A beverage was observed to be stored next to the juice dispenser on top of a table. Food to be discarded from resident breakfast was observed to be on top of the steam table used to hold hot foods. There was a sealed bag containing an unknown food item that was green and red in the freezer without a label or a date of expiration or preparation. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the physician was notified regarding changes in a catheter output for one resident (#132) of one observed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected active diagnoses for one resident (#73) of three residents sampled. Cross-reference F645.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident referral for a Level II Preadmission Screening and Resident Review (PASARR) review following qualifying diagnosis for one resident (51) out of four residents sampled for PASARRs. Record review for Resident #51 revealed a diagnosis of Post-Traumatic Stress Disorder (PTSD), unspecified, with an admission date of 08/09/2025. Further review of Resident #51's psychiatry progress notes dated 3/9/2026 and 4/10/2026 revealed an assessment treatment plan for diagnoses to include Major depressive disorder, generalized anxiety disorder, insomnia due to other mental disorder, mood lability, borderline personality disorder and psychotic disorder with delusions due to a known physiological condition. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure bedfast residents with limited mobilities received activities to meet the interests and support the physical, mental and psychosocial well - being for one resident (#83) of one resident reviewed.

Inspectors wroteBased on observations interviews and record review the facility failed to provide timely care and assistance for residents needing staff's help for two residents (#132 and #109) of two residents reviewed. Resident #132 waited for one hour to be repositioned resulting in on-going pain, and Resident #109 waited for assistance off the floor for 45 minutes post fall.

Inspectors wroteBased on observation, record review, and interviews the facility failed to provide enteral nutrition as ordered by the physician for one resident (#34) out of two sampled.

Inspectors wroteBased on interviews and record reviews the facility did not ensure medications were correctly reconciled upon admission to the facility for one resident (#131) of one resident sampled, resulting in delayed medical intervention and pain.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for two residents (#6 and #68) out of five residents sampled for medication administration. This resulted in 2 errors out of 29 medication administration opportunities for a medication error rate of 6.9%.

Inspectors wroteBased on observations, interviews, and record reviews the facility did not ensure therapy or restorative service were provided for two residents (#68, and #83) of two residents sampled.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an effective infection prevention program related to accurate signage posting for one resident (#18) out of one resident sampled for contact precautions.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure food in the refrigerator was discarded upon the expiration date and the facility failed to ensure the facility had and followed a cleaning schedule for food service equipment for one of one kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received respiratory services consistent with professional standards of practice related to oxygen administration and respiratory equipment storage for four residents (#99, #78, #42 and #83) out of four sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin according to physician orders for one resident (#65) out of two residents reviewed for insulin administration.

Inspectors wroteBased on interview and record review the facility failed to ensure physician ordered parameters were followed related to hypertensive medications resulting in the administration of unnecessary medications for one resident (#106) out of five residents reviewed for unnecessary medications. Review of Resident #106 admission record documented diagnosis of unspecified atrial fibrillation, heart failure unspecified, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease unspecified, type 2 diabetes mellitus without complications, unspecified osteoarthritis unspecified malignant neoplasm of esophagus unspecified, and atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain). [...]

Inspectors wroteBased on observation, interview, and record review and policy and procedure review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases for three residents (#1, #14, #44 and #27) out of seven residents sampled for infection control.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dignity to one resident (#108) out of two sampled residents related to a catheter bag covering.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment and implement their policy on securing smoking materials in a secure location for one resident (#3) out of three residents reviewed for accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure midline catheter dressing changes were completed according to professional standards of practice for one resident (#111) of one resident reviewed with a midline catheter.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy reviews were conducted monthly and the facility failed to ensure a physician provided a clinical rational for two residents (#11 and #51) out of five residents reviewed for medication regimen review (MRR).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADLs) were performed for one (#3) three sampled residents related to incontinence care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Quality of Care was provided related to wound care and following Infection Control Practices for one (#3) of one sampled resident.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and seven errors were identified for three (#73, #11, and #446) of four residents observed. These errors constituted a 25.93% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one (#4) of one resident sampled for self-administration of medications was assessed for the administration of nebulizer treatments.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents received medications in accordance with professional standards related to monitoring of blood pressure medications parameters and to ensure the physician was notified of held doses for one (#56) of six residents sampled for unnecessary medications.

Inspectors wroteBased on observations, interviews and records review, the facility did not ensure a resident with contractures received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence. The facility failed to ensure restorative services were provided for one (Resident #56) of 14 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a pain assessment was conducted in a timely manner for one (Resident #13) of two residents reviewed for pain.