Hillside Manor

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 (R9) of 2 residents reviewed for PIs out of a sample of 15 residents. R9 had a care plan intervention to use a Roho cushion in R9's wheelchair and recliner. The facility staff failed to ensure the Roho was properly inflated and functioned according to manufacturer's recommendations and failed to ensure weekly skin assessments were completed once R9 developed a full thickness.

Inspectors wroteBased on observation, interview, and record review the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 58 residents. Surveyor observed dried food drips on the outside of the oven doors. Surveyor observed personal, unmarked food in the beverage cooler. Surveyor observed a half loaf of bread undated and with visible freezer burn in the freezer. Surveyor observed burger patties improperly sealed in the freezer. Surveyor observed dessert bars not dated or marked and not properly closed in the bakery freezer. Surveyor observed trash cans in the food prep area to not have lids. Surveyor observed that the test strips to test the parts per million for the sanitizing buckets and three compartment sink were damaged and unusable. [...]

Inspectors wroteNumber of residents sampled: 6Number of residents cited: 4Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 11 errors out of 37 opportunities that affected 4 (R3, R8, R15, & R4) out of 6 residents included in the medication pass task, which resulted in an error rate of 29.73%. RN N (Registered Nurse) did not follow facility policy or current standard of practice for the administration of R3's Daptomycin (Antibiotic) through a PICC (Peripherally Inserted Central Catheter) line. MT (Medication Tech) O did not administer the correct dose for R8's ipratropium bromide 0.06% inhalation solution (Nasal spray used to relieve runny nose). Instead of the ordered 2 sprays in each nostril, R8 was only administered 1 spray in each nostril. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with 1 of 3 residents (R61) physicians when there was a significant change in the resident's physical status. The facility did not immediately contact a physician after R61 experienced decreased peripheral capillary oxygen saturation (SPO2) on two (2) consecutive days. This is evidenced by:The facility policy titled Resident Change in Condition Policy with a review date of 9/29/25 states in part; an Registered Nurse (RN) will assess residents exhibiting a change in condition and will inform resident, their physician, and responsible party. 3.1 The Nursing staff will update the residents attending physician or designee when: b. There is a significant change in the residents' physical, mental, or psychosocial status. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide nail care assistance for 1 of 1 (R19) dependent resident reviewed for Activities of Daily Living (ADLs) assistance. Staff did not assist R19 with nail care assistance even after Surveyor informed staff that the nails were digging into the palm of R19's contracted hand. Evidenced by:Facility policy, titled Foot and Nail Care for Long Term Care Residents, dated 11/28/22 with last review date of 12/31/24, states, . Purpose: To provide a consistent and safe method for the provision of foot and nail care for all adult residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate interventions were in place for safety to prevent accidents from occurring for 1 of 3 residents (R4) reviewed for falls. R4 was admitted with a known history of falls. The facility did not ensure adequate fall interventions were in place upon admission, resulting in R4 having a fall with a distal fibular (lower end of the calf bone near the ankle) fracture. Evidenced by: The facility's policy titled, Fall Prevention and Management Procedure, dated 12/19/24, indicates, in part: Purpose Statement: To establish procedure for residents at risk for falls; to systemically assess fall risk factors; provide guidelines following a fall and resident specific fall preventive interventions. 3.1 Fall Risk - Individual Resident: a. Upon admission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure nursing staff followed professional standards of practice when flushing a peripherally inserted central catheter (PICC) for 1 of 1 resident (R3) reviewed for intravenous medication administration. RN N (Registered Nurse) did not follow facility policy or current standard of practice for the administration of R3's Daptomycin (Antibiotic) through a PICC (Peripherally Inserted Central Catheter) line. RN N failed to check for blood return prior to administering the intravenous medication. RN N also failed to set the pump to administer the medication according to physician order. Evidenced By: The facility policy titled, Peripherally inserted central catheter (PICC) drug administration, dated 9/14/25, states, in part: . Implementation . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature for 1 of 15 sampled Residents (R19) R19 stated they were served cold food at meals. 1 of 1 test trays were observed to have food being served at undesirable temperatures. Evidenced by: The facility policy, titled Food and Nutrition - Tray Line Taste and Temperature Log Procedures, dated 10/15/24, includes in part: .3.1 Meals Served at Set Time. food is served at the appropriate temperature. to monitor taste and temperature on the service line for patient/resident food service. standard temperatures. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 Residents (R41) reviewed for catheters. R41 has a history of bladder disorders and MRSA (methicillin-resistant Staphylococcus aureus, a bacteria that is resistant to many antibiotics) in the urine. CNA M (Certified Nursing Assistant) did not utilize aseptic technique to minimize the risk of cross contamination from microorganisms in the environment. Evidenced by:The facility's policy, Perineal Care/Catheter Care, dated 1/3/22 with last review date of 12/31/24, states, in part: Purpose:. Residents with indwelling catheters will receive catheter care with morning and evening cares, or as indicated in the plan of care. 3.1 Steps for Perineal Care:. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 out of 4 sampled residents (R1) by failing to serve R1 the correct diet and failing to administer first aid (Heimlich Maneuver) timely when R1 experienced a choking episode. R1 experienced a choking episode that required the Heimlich maneuver to clear R1's airway. The facility did not complete all assessments of Vital Signs (VS) and respirations over the next 24 hours. At supper the following day, the facility did not ensure that R1 received the proper downgraded diet of bite sized and soft food items. R1's meal card indicated R1 could be served a dinner roll, which was served. R1's new downgraded diet does not allow dinner rolls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision to prevent accidents for 1 of 2 Residents (R3) reviewed for dining supervision. R3 is care planned for feeding assistance and direct supervision with meals and was observed eating in dining room with no staff seated at table. Evidenced by:Surveyor requested dining / meal supervision policy. NHA A (Nursing Home Administrator) indicated that the facility does not have a separate policy, but follows state and federal regulations for adequate supervision for residents as denoted on the individual care plan. R3 was admitted to the facility on [DATE] and has diagnoses that include Parkinson's disease with dyskinesia (a progressive neurological disorder that primarily affects movement, causing symptoms like tremors); [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents were seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter for 1 of 1 residents (R1) reviewed for physician visits. R1 was not seen by a provider at least once every 30 days for the first 90 days after admission. This is evidenced by:Facility policy, titled Physician Visits Policy, reviewed 12/31/24, includes: The physician needs to see a newly admitted resident at a minimum of once every 30 days for the first 90 days and then at least every 60 days thereafter. R1 was admitted to the facility on [DATE] with diagnoses that include, in part: unspecified dementia, severe, with mood disturbance (a condition with a decline in mental ability severe enough to interfere with daily life); unspecified dementia, severe, with anxiety; [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure prompt resolution of all grievances for 2 of 3 residents (R1 and R2) reviewed for grievances. R1's Representative voiced concerns related to R1 sitting wrong in a shower and rushing R1 with meals not allowing her to finish. The facility failed to follow up on these concerns using their grievance policy and procedure. R2's Resident Representatives voiced concerns during a meeting and these concerns were documented in R2's medical record. The facility failed to follow up on concerns using the facility's policy and procedure for grievances. Evidenced by: Facility policy, titled Resident Rights/Organizational Ethics Policy, reviewed 12/31/24, includes: [...]

Inspectors wroteBased on interview and record review, the facility did not complete a thorough investigation in response to a potential allegation of abuse for 1 of 3 residents (R1) reviewed for abuse. On 5/31/25, the facility became aware of an alleged injury of unknown origin due to discolored (yellow) areas on R1's right knee and left ankle. The facility did not interview other like residents as part of the investigation. Evidenced by: The facility's Reporting of Caregiver Misconduct in the Skilled Nursing Facility policy, dated 12/31/24, states, in part: .c. Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out potential abuse . e. The investigation will consist of at least the following: [...]

Inspectors wroteExample 2 R12 was admitted to the facility on [DATE] with diagnoses that include, in part: repeated falls, pain in left hip, age-related osteoporosis, overactive bladder, chronic pain syndrome, depression unspecified, mild cognitive impairment of uncertain or unknow etiology, age related cataract, sensorineural hearing loss, and nausea. R12's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 11/5/24, indicates R12 has a BIMS (Brief Interview of Mental Status) of 5 out of 15, indicating R12 has severe cognitive impairment. R12's fall care plan, includes, in part: --Problem: I have a history of falls due to my choice to transfer/ambulate without staff assistance. I am aware that I require assistance to maintain my safety, but often do not ask for help. I have weakness and impaired judgement. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect the total census of 52 residents. Residents (R) voiced concerns of food not being served at a desirable temperature (R32, R41, R46, and R28). 2 of 2 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility policy, titled Food and Nutrition - Trayline Taste and Temperature Log Procedure, dated 10/15/24, includes in part: . The purpose of Menu Works Daily Service Patient/Resident Taste and Temperature Log is to monitor taste and temperatures on the service line for Patient/Resident food service . Standard Temperatures . Hot Entrees >= 140 degrees Fahrenheit . Hot Vegetables >= 140 degrees Fahrenheit . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 52 residents. Surveyor observed items opened and undated in the refrigerators and coolers. Surveyor observed food items unsealed and/or unmarked in the freezers. Surveyor observed boxes stored on the floor of the freezer. Surveyor observed the facility's meat slicer to be stored uncovered and mixer to be unclean. Surveyor observed a scoop in the powdered sugar container in the food preparation area. Surveyor observed dietary staff touch dirty dishes and then ready to eat food items without performing hand hygiene. Evidenced by: Example: Opened and undated items Facility policy, entitled Food and Nutrition - Food Handling Guidelines dated 6/20/22 states in part, . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This has the potential to affect all 52 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for one fiscal year quarter for one star staffing rating, excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours a day. Evidenced by: The facility's Payroll Based Journal Entry Procedure policy, dated 11/15/24, states, in part: . 3.6 Data submission will be verified for accuracy prior to the reporting deadline by the designated HSM (Hillside Manor) scheduler/employee. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 3 of 3 residents (R16, R26, R41) with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and provide dignity for residents. R16, R26, and R41 were observed with their catheter drainage bag uncovered. Evidenced by: The facility's policy titled Resident Rights Policy last reviewed on 2/28/24, states in part .Dignity and Respect: a. This facility will care for each of its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. b. We will promote their right to receive care and treatment in a manner and in an environment that maintains or enhances their dignity and respect in full recognition of their individuality . [...]

Inspectors wroteBased on interview and record review the facility failed to immediately consult with physician when needing to alter treatment for 1 (R37) of 3 residents reviewed for physician notification. R37 had an unwitnessed fall on 9/6/24. The facility did not call the on-call physician when R37 reported increased complaints of pain. R37 was found to have a distal clavicle fracture. Evidenced by: The facility's policy titled Resident Change in Condition Policy last reviewed on 12/12/23, states in part .The Nursing Staff will update the resident's attending physician when: .c. There is a need to alter the resident's treatment .f. Deemed necessary or appropriate in the best interest of the resident . [...]

Inspectors wroteBased on interview and record review, the facility did not develop a comprehensive, person-centered care plan for 1 (R26) of 15 residents reviewed for care plans. R26's care plan does not include a problem, goal, and interventions for pain or anxiety. Evidenced by: The facility's Psychotropic Medication Use/Chemical Restraints policy, dated 12/14/23, states, in part: . 3.1 Physicians / providers must order psychotropic medications only when all other attempts at redirection and non-pharmacological interventions have failed and are documented.3.7 The Care Plan will be developed with assistance of the interdisciplinary team, resident, and family members. The Care Plan will define the behavior as well as the goals for the resident. 3.8 Each care plan will also provide specific and individualized instructions for staff to follow to assist with behavior concerns. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the medication regimen of each resident was reviewed at least once a month by a licensed pharmacist for 1 of 5 residents reviewed for unnecessary medications (R26). R26 did not have a monthly medication review conducted by a pharmacist. This is evidenced by: The facility's Role of the Pharmacist in Long Term Care Procedure policy, dated 7/8/24, states, in part: .2.2 Definitions . Monthly Medication Regimen Review: The process by which a consultant pharmacist analyzes a LTC (long term care) resident's medical chart, medication administration record, and pharmacy software on a monthly basis in order to prevent, identity, report, and resolve medication-related problems, medication errors, and other irregularities.3.1 The consultant pharmacist will perform the following: a. [...]

Inspectors wroteBased on interview and record review the facility did not ensure Residents (R) receiving a psychotropic medication, were free from unnecessary medications for 1 of 15 Residents (R52). R52 receives antidepressant and antipsychotic medications. The facility is not monitoring for side effects of antidepressant and antipsychotic medications. This is evidenced by: Facility policy titled Mood/Behavior Policy dated 11/28/22 with last revision date 12/14/23, states in part: .The (Facility Name) Behavioral Program will include a systemic care process to assure that assessments are accurate and timely; interventions are implemented, monitored, and revised as appropriate. (Facility Name) will provide appropriate care and services . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure it was free of medication error rates of 5% or greater. There were 8 errors in 25 opportunities that affected 1 resident (R39) out of a sample of 6 residents observed for medication administration. This results in an error rate of 32%. R39's medications were scheduled for 8:00 AM and R39 received her medications at 10:02 AM. Evidenced by: The facility's policy titled Basic Medication Administration Policy last reviewed on 12/11/24, states in part: .3.4 General Medication Administration: .c. All medications must be given within 1 hour before or 1 hour after scheduled time . On 11/11/24 at 10:02 AM, Surveyor observed RN I (Registered Nurse) during medication administration. Surveyor observed RN I give the following medications to R39: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure drugs and biologicals are labeled in accordance with currently accepted professional standards for 2 of 2 medication carts reviewed for medication storage. The medication cart on Swan hall contained an expired bottle of Atropine 1% eye drops for R40. The medication cart on Monarch hall contained a Combivent Respimat inhaler that was not labeled or dated. As evidenced by: Facility policy entitled, Basic Medication Administration Policy dated 3/4/2024 states, in part .3.4 Medication Storage .c. All medication not contained in an automated dispensing cabinet (ADC) or carousel: Medications for individual resident use will be labeled and stored in resident specific bins or drawers and labeled with a room number .f. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide food that accommodates resident preferences; appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 1 of 1 sampled resident's (R36). R36 was not being served the menu items of their preferences or offered appealing options of similar nutritive value. As evidenced by The facility policy, Food and Nutrition-Patient Menus Selections Procedure, revised 10/15/24, documents in part, as follows: Purpose statement: Patient food preferences are respected, and appropriate dietary substitutions are made. Develops an alternative menu, which is a list of standard options which the Food Service Associate can offer within the limits of the diet order. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 56 of 56 residents residing in the facility. Staff did not complete appropriate hand hygiene during two meal service observations. A juice machine and multiple microwaves were not in clean condition. Food holding temperatures were not monitored or documented.

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 Resident (R) (R32) of 17 residents. On 7/21/23, R32's family reported R32's wallet and purse were missing. The facility did not report the allegation of misappropriation to the State Agency (SA) or local law enforcement.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 Resident (R) (R2) of 3 residents observed during the provision of cares. Certified Nursing Assistant (CNA)-C did not appropriately cleanse hands during the provision of perineal care for R2.