Hillside Manor Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to ensure residents did not develop new pressure ulcers and ensure services were provided for treatment of pressure ulcers for 2 of 3 residents reviewed for pressure ulcers (Resident B and Resident C). Resident B developed a Stage III pressure ulcer, and routine wound care orders were not followed. Full wound assessments were not completed routinely, and wound treatments were not documented as completed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in accordance with food safety standards to maintain a sanitary environment and prevent foodborne illness during 2 of 2 kitchen observations. Frozen food was stored uncovered, kitchen staff rested a pair of tongs against a cleaning towel during meal service, the backsplash behind the three-compartment sink appeared unclean and discolored, and a live roach was observed in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse was serving as the Director of Nursing (DON) on a full time basis (40 hours per week) for 1 of 1 DON reviewed. The facility had an interim DON that was not working on a full-time basis. (DON)

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were certified to fill the role of a Certified Nurse Aide (CNA) for 1 of 5 CNA licenses reviewed. An employee was working as a CNA without being certified. (CNA 24)

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate certification of the Kitchen Manager for 1 of 1 employee identified as Kitchen Manager. The current Kitchen Manager was not certified in food safety or food service management. (Kitchen Manager)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Food items were open to air and not labeled, refrigerator temperatures were not recorded, and debris was observed in the refrigerators.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure waste was properly contained in dumpsters for 2 of 2 random observations. Staff observed to place garbage bags on top of the dumpster lid, and trash was observed on the ground around the dumpster.

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individual(s) as the Infection Preventionist with qualifying training or certification for 7 of 7 days of the survey. The facility did not have a current certified Infection Preventionist.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing resident centered activity program for 2 of 2 halls in the facility. The activity calendar was not followed and resident's interviews indicated there weren't enough activities. (Front Hall, Back Hall)

Inspectors wroteBased on interview and record review, the facility failed to ensure the Activity Director was certified for 1 of 1 Activity Director reviewed. (Activity Director)

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 1 of 1 medication carts observed. Medication cups with loose pills and a narcotic was observed in a medication cart. (Resident 7, Resident 15, Resident 24, Resident 30)

Inspectors wroteBased on interview and record review, the facility failed to ensure diets were provided that met nutritional and special dietary needs for 12 of 35 residents that ate facility provided meals. All residents were served a regular diet despite other therapeutic diet orders. (Resident 4, Resident 9, Resident 11, Resident 13, Resident 20, Resident 3, Resident 29, Resident 8, Resident 30, Resident 22, Anonymous Resident A, Anonymous Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had a diet ordered by a prescribing practitioner for 3 of 15 residents reviewed for diet orders. The resident orders did not include an order for a diet. (Resident 7, Resident 23, Resident 10)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for 2 of 2 observations of the basement and laundry room. The basement floor was full of dirt and debris, vent covers were caked with dust, and the laundry room had debris and dust. (Basement, Laundry Room)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was informed in advance by the prescribing practitioner of the risks and benefits of proposed treatment and treatment alternatives for 1 of 6 residents reviewed for unnecessary medications. A prescribing practitioner ordered an antipsychotic for a resident they had not seen and the clinical record lacked documentation of education provided to the resident prior to the medication being given. (Resident 23)

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate representation of advanced directive status for 1 of 2 residents reviewed for advance directives. A resident's actual code status was not reflected accurately in all documentation. (Resident 32)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was discharged with sufficient preparation for 1 of 1 closed records reviewed. A discharged resident was not educated to follow up with a specialist as needed, and a current list of medications was not provided. (Resident 38)

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) Assessment was completed for 3 of 12 residents reviewed for MDS Assessments. Residents taking anticonvulsant medications, antianxiety, and hypoglycemic medications were not marked as administered. (Resident 3, Resident 8, Resident 2)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate care and services for a suprapubic catheter were given for 1 of 2 residents reviewed for catheter care. Staff was not measuring output and not cleaning the insertion site of a resident with a suprapubic catheter. (Resident 7)

Inspectors wroteBased on interview and record review, the facility failed to receive registry verification before filling the role of a Certified Nurse Aide (CNA) for 1 of 5 CNA licenses reviewed. An employee was working as a CNA without the facility verifying registration. (CNA 24)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure person-centered dementia treatment and services were provided for 1 of 2 residents reviewed for dementia care. (Resident 7)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 2 residents reviewed for urinary tract infections (UTI). A resident was given medications that caused severe sedation when taken together resulting in unresponsiveness and a subsequent hospitalization. (Resident 6)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure accurate documentation for 3 of 6 residents reviewed for unnecessary medications. Resident's Medication Administration Record (MAR) lacked documentation of medications and treatments that were received. (Resident 3, Resident 7, Resident 23)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Residents were not placed on Enhanced Barrier Precautions (EBP) when indicated for 1 of 1 resident reviewed for catheter care. (Resident 6)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an antibiotic stewardship program was used to monitor appropriate use of antibiotics for 2 of 2 residents reviewed for antibiotic use. Resident antibiotic orders were not followed. (Resident 6, Resident 7)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Posted Nurse Staffing form was posted on a daily basis at the beginning of each shift for 3 of 6 days reviewed for the survey. The Posted Nurse Staffing form was not updated on a daily basis. (12/4/25, 12/5/25, 12/8/25)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent a resident with a history of exit-seeking behavior and elopement from exiting the facility and leaving the property for 1 of 1 resident reviewed for elopement. This deficient practice resulted in an elopement that occurred on the evening of August 30, 2025. The resident was located with the assistance of the local police department, approximately 0.6 miles from the nursing facility, hiding behind an air conditioning unit near the intersection of National Highway and State Road 57. This Immediate Jeopardy began on August 30, 2025, when the facility failed to ensure Resident C did not exit the facility property by climbing a gazebo and jumping over a fence that enclosed an outside courtyard. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 1 of 2 resident shower rooms, 1 of 2 dining rooms, and 1 of 2 halls observed and clean linens were not covered during transport in resident halls. Overhead air vents contained a build up of dust in and around the vent, a dining room floor was uneven and flooring was raised or warped, and a shared shower room contained multiple broken floor tiles, appeared unclean, and contained a small swarm of gnats and flies near the commode. (North Unit, South Unit, North Unit dining room, and Middle-hall shower room, Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications to 1 of 3 residents reviewed for pharmacy services. Following a change in a resident's routine medications, the facility failed to obtain an ordered routine medication which resulted in multiple missed doses of the medication. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 1 of 2 resident rooms observed for water temperatures and 1 of 2 resident shower rooms observed for water temperatures, for 1 of 2 dining rooms observed for air temperatures and disrepair, and 2 of 4 resident room observed for disrepair. A shared resident restroom's water temperature reached 140 degrees Fahrenheit (F), a shared resident shower room's water temperature reached 140 degrees F, the North Unit Dining room reached 89 degrees F, floors were uneven and wet from a leaking air conditioning (AC) unit, two resident rooms' flooring was in disrepair, and one resident room's ceiling contained water damage. (Resident B, Resident C, Resident D, Resident F, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER],. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete and accurate facility assessment based on the resident population and identification of resources needed to provide the necessary care and services required for their residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The IP had not received specialized training in infection prevention and control, and did not currently dedicate at least part time to the role of IP for 1 of 1 staff members reviewed for IP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents right to participate in the development and implementation of his or her person-centered plan of care for 10 of 32 residents reviewed for narcotic use. The facility had implemented a facility-wide rule to crush all narcotics for every resident without resident input or obtaining a physician order to do so. (Resident 2, Resident 21, Resident 3, Resident 13, Resident 4, Resident 15, Resident 29, Resident 5, Resident 17, Resident 11)

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) Assessment was completed for 5 of 14 residents reviewed for MDS Assessments. Residents taking antiplatelet medication, diuretics, and oxygen were not marked as administered. (Resident 16, Resident 15, Resident 7, Resident 25, and Resident 6).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident for 6 of 6 residents reviewed for unnecessary medications. Residents on antipyschotic, antidepressant, antianxiety, and diuretic medications and a resident on oxygen did not have care plans developed. (Resident 15, Resident 16, Resident 7, Resident 25, Resident 6, Resident 28)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received necessary respiratory care and services in accordance with professional standards of practice. The facility failed to have an order for oxygen use, follow physician oxygenation orders, date oxygen tubing, and clean the oxygen filters for 4 of 5 residents reviewed for respiratory care. (Resident 5, Resident 23, Resident 14, Resident 6)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all physician's orders were obtained from the pharmacy for 1 of 6 residents reviewed for medication administration and 3 of 5 residents reviewed for respiratory care. The facility lacked August 2024 physician orders for insulin and oxygen. (Resident 14, Resident 5, Resident 23, Resident 2)

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 2 of 2 medication carts observed and 1 of 2 medication storage rooms observed. Medications with no open date were observed in the medication carts, and refrigerator temperature logs were not filled out completely in the medication room. (Back Hall Medication Cart, Back Hall Medication Storage Room, Front Hall Medication Cart)

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchens observed. Staff did not wear hairnets that covered all their hair, appropriate footwear was not worn, food was not labeled, the dishwasher was not monitored daily for safe sanitation, staff did not wash hands for appropriate length of time, and scoops were left in containers. (Kitchen)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Gloves were not changed between dirty and clean tasks, hands were not sanitized between changing gloves, a resident was not completely cleaned, and staff did not offer a resident the opportunity to wash hands after toileting for 4 of 5 resident observations of incontinence care. Staff did not cover clean clothing when transporting clean clothes to residents, and carried clean clothes against their uniform top when carrying for 2 of 2 observations of linen handling. Residents were not placed on Enhanced Barrier Precautions (EBP) when indicated for 6 of 6 residents with wounds, 2 of 2 residents with urinary catheters, and 1 of 1 residents with a stoma. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment for 1 of 1 resident communal restrooms and 3 of 3 shower rooms observed. A three-quarter inch gap was observed on 1 of 2 doors to the courtyard. A random couch was observed to have fabric peeled off of it in 1 of 2 common areas. A brown substance was observed around the bottom of toilets, doors had chips, toilet paper holders were rusted, gnats were on the floor, tile was missing in the shower, spiderwebs were on the ceiling, and grout was soiled. (Front Hall Shower Room, Middle Hall Shower Room, Back Hall Shower Room, Communal Restroom)

Inspectors wroteBased on observation and interview, the facility failed to ensure an effective pest control program to keep the facility free of pests and rodents. (Downstairs Dry Storage Room)

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine that self-administration of medications was clinically appropriate for 1 of 2 residents reviewed with medication in their room. A resident had an Albuterol inhaler in her room without an order to keep at the bedside or a self-administer assessment. (Resident 5)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised for 3 of 12 residents reviewed for care plans. A care plan was not revised to include bed rails as a fall intervention, and care plans were not revised after medications were discontinued. (Resident 2, Resident 16, Resident 15)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective services were provided to prevent the development of a facility-acquired stage three pressure injury and multiple stage two pressure injuries for Resident 28, who was admitted to the facility without pressure injuries, and were identified by the facility upon admission to be at risk to develop pressure injuries. (Resident 28)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for 2 random observations of residents having vapes (electronic cigarette) in their possession. (Resident 15, Resident 24)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure clinical record documentation was complete and accurate for 1 of 2 residents reviewed for hospitalizations and 1 of 1 residents reviewed for general skin conditions. (Resident 15, Resident 23)

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff based on the needs of the resident population in the facility for 2 of 3 residents reviewed for accidents and 1 of 1 residents reviewed for having a diagnosis of PTSD (Post Traumatic Stress Disorder). (Resident 15, Resident 24)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient behavioral health care for 1 of 1 residents reviewed for elopement. A resident with documented behaviors was not provided additional monitoring or services during a behavioral episode that resulted in the resident eloping from the facility, unwitnessed. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure that complete and accurate records were maintained for 2 of 4 resident records reviewed. A resident's record contained no documentation of an elopement occurrence, nor were the behaviors that reportedly led up to the incident or any monitoring following the elopement documented. A resident's wound treatment orders were not updated in the resident's record and wound treatment documentation was not completed accordingly. (Resident B, Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 1 of 2 resident rooms observed for water temperatures and 2 of 2 shared resident shower rooms observed for water temperatures. Resident rooms and restrooms were not cleaned and/or needed repairs for 3 of 6 rooms observed and 1 of 2 shared shower rooms observed. Residents indicated their shared bathrooms are not cleaned daily, flooring was damaged around a commode and plumbing was leaking onto the bathroom floor, a wall cover was loose and exposing a hole used for plumbing, commodes appeared to be unclean, a soap dispenser was dripping soap onto a towel placed on the floor, and a shared shower room had broken tiles, a towel left on the floor, and a wall behind the commode had not been cleaned. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) Assessment was completed for 3 of 5 residents reviewed for unnecessary medications and 3 of 7 reviewed during initial record review and 1 of 3 observed during care. Two residents had medications that were not signed off in the MAR (Medication Administration Record) as given for 7 days in the MDS. The MDS for four residents indicated they had a medication being given when one was not ordered. One resident was independent with transfers when the MDS indicated he needed extensive assistance of 2 staff for transfers. (Residents 4, 9, 13, 17, 29, 30, 35, and 39)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 1 residents observed with medications in their rooms. The facility failed to obtain a Physician's Order to self administer medications. (Resident 18)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice. The facility failed to obtain a Physician's Order for oxygenation. (Resident 18)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 1 insulin administration. The nurse failed to prime the insulin pen before administering insulin to a resident. (Resident 139)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 3 of 3 residents during observation of perineal care. Gloves were not changed between dirty and clean tasks during peri care, staff failed to wash hands or sanitize between dirty and clean tasks. (Resident 4, Resident 17, Resident 35)

Inspectors wroteBased on interview and record review, the facility failed to ensure all direct care staffing data was submitted into the Payroll-Based Journal (PBJ) system for the reported period of April 1, 2023 through June 30, 2023.