Hillside Manor Rehab & Extended Care Center

Inspectors wroteBased on observations, record reviews, and staff interviews conducted during an Abbreviated Survey (NY00385241), the facility failed to ensure that a resident's Advance Directives for Do Not Resuscitate were followed. This was evident for one (1) out of ten (10) residents sampled. Specifically, Resident #1 had a signed Medical Order for Life Sustaining Treatment indicating Do Not Resuscitate. Resident #1 was observed not breathing and without vital signs on [DATE] at 8:30 AM and staff performed Cardiopulmonary Resuscitation. According to several staff interviews, Resident #1 received Cardiopulmonary Resuscitation efforts until staff members learned that Resident #1 was a Do Not Resuscitate. Emergency Medical Services had previously been called, and they pronounced the resident at 8:53 AM after they learned that the resident had a Do Not Resuscitate order in place.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet each resident's medical, nursing, mental, and psychosocial needs. This was evident in 2 of 2 residents reviewed out of 35 total sampled residents. Specifically, 1.) Resident #27, who was on palliative care and had been receiving pain medications, had no care plan developed to address pain management and palliative care. 2.) Resident #123, who had a diagnosis of Diabetes Mellitus and had been receiving medications to help control their blood sugar level, had no care plan developed for diabetes.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 03/24/2025 to 03/31/2025, the facility did not ensure that services provided meet professional standards of quality. This was evident for 1 (Resident #320) of 3 residents observed during Medication Administration. Specifically, 1) Licensed Practical Nurse #3 was observed administering the medication Janumet 50 mg-500 mg 1 tablet by mouth at 10:05 AM, however, review of the Medication Administration Record documented the medication had been administered at 7:49 AM, and 2) Licensed Practical Nurse #3 was also observed administering Centrum Silver Ultra Men's 300 mcg-60 mcg-600 mcg-300 mcg 1 tablet by mouth that was dispensed for Resident #318 to Resident #320 instead of Centrum Silver 0.4 mg-300 mcg 250 mcg 1 tablet by mouth as ordered by the physician.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that the medication error rate was not less than 5 percent. This was evident for 2 of 28 medications given during the Medication Administration task. Specifically, 1) Licensed Practical Nurse #3 was observed administering the medication Janumet 50 mg-500 mg 1 tablet by mouth at 10:05 AM, however, review of the Medication Administration Record documented the medication had been administered at 7:49 AM, and 2) Licensed Practical Nurse #3 was also observed administering Centrum Silver Ultra Men's 300 mcg-60 mcg-600 mcg-300 mcg 1 tablet by mouth that was dispensed for Resident #318 to Resident #320 instead of Centrum Silver 0.4 mg-300 mcg 250 mcg 1 tablet by mouth as ordered by the physician which resulted in a medication error rate of 7. [...]

Inspectors wroteBased on record review and interviews during the Recertification and Abbreviated Survey (NY00342691) conducted from 03/24/2025 to 03/31/2025, the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made to the New York State Department of Health. This was evident in 1 (Resident #230) of 3 residents reviewed for Abuse. Specifically, Resident #230 had an unwitnessed incident on 05/17/2024 at approximately 4:00 AM, when the resident was observed sitting on the floor gym mat on the left side of their bed. Hospital x-ray report showed right pelvic fracture. Resident #230 was unable to explain the occurrence. This incident was not reported to the New York State Department of Health.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated and Partial Extended Survey (NY00354577), the facility failed to protect the residents' right to be free from physical abuse. This was evident for one out of six residents reviewed (Resident #1) for abuse. Specifically, on 09/16/2024 at 7:20 PM, Licensed Practical Nurse #1 did not intervene or remove Certified Nursing Assistant #1 from providing care to Resident #1 or any other residents assigned to Certified Nursing Assistant #1 when on 1) 09/16/2024 at around 7:20 PM, Licensed Practical Nurse #1 witnessed Certified Nursing Assistant #1 physically force Resident #1 to sit in a chair in the hallway; [...]

Inspectors wroteBased on observation, record review, and interview during an Abbreviated and Partial Extended Survey (NY00354577), the facility failed to remove Certified Nursing Assistant #1 from resident care after witnessed abuse. This was evident for one out of six residents reviewed (Resident #1) for abuse. Specifically, 1) On 09/16/2024 at around 7:20 PM, Licensed Practical Nurse #1 witnessed Certified Nursing Assistant #1 physically force Resident #1 to sit in a chair in the hallway; 2) between 8:15 PM - 8:30 PM Licensed Practical Nurse #1 and Certified Nursing Assistant #2 both witnessed Certified Nursing Assistant #1 grab and push Resident #1 to sit in a wheelchair and then wheel Resident #1 into their room; [...]

Inspectors wroteBased on observation, record review, and interview during an Abbreviated and Partial Extended Survey (NY00354577), the facility's administration failed to ensure that the facility was operated in a manner that use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident in one out of six residents sampled (Resident #1). Specifically, on 09/16/2024, the facility did not intervene or remove Certified Nursing Assistant #1 from the unit resulting in further abuse to Resident #1. Administration failed to ensure in-service lesson plans provided guidance to facility staff on how to protect residents from suspected or witnessed abuse.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure that each resident was treated with respect and dignity. This was evident for 1 (Resident #256) of 38 total sampled residents. Specifically, Licensed Practical Nurse (LPN) #2 and Certified Nursing Assistant (CNA) #1 were observed standing over Resident #256 while feeding them.

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to the Centers of Medicare/Medicaid Services Data System (CMSDS) within 14 days of completion. This was evident for 1 (Resident #138) of 17 residents reviewed for resident assessment out of 38 total sampled residents. Specifically, Resident #138's MDS assessment was not transmitted within 14 days of completion.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflect the resident status. This was evident for 2 (Resident # 342 and # 80) of 38 total sampled residents. Specifically, 1) the MDS assessment for Resident # 342 did not accurately capture their discharge to the community, and 2) the MDS assessment for Resident # 80 did not accurately capture behaviors of refusal and rejection of care and treatment.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure separately locked, permanently affixed compartments for storage of controlled drugs. This was evident for 1 (5th Floor) of 5 units observed for medication storage. Specifically, the Controlled Medications (CM) cabinet on the 5th Floor was observed with 1 lock that was not functional.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure food was stored according to professional standards for food safety. This was evident for 1 (5th Floor) of 10 floor unit pantries observed during Kitchen review. Specifically, the pantry refrigerator was above 41 degrees Fahrenheit (F) and contained undated and unlabeled food.

Inspectors wroteBased on observation and interview, during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, staff were observed not wearing hairnets appropriately while in the kitchen. This was evident during the Kitchen facility task.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided. Specifically, torn privacy curtain, peeling wall paper, and a soiled feeding tube pole was observed. This was evident on 2 of 8 units during Environmental rounds. (Unit 2 and Unit 3)

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that a resident/resident representative was invited to participate in care plan meeting. Specifically, residents/representatives were not invited to the quarterly care plan meeting. This was evident for 3 out of 4 residents reviewed for Care Planning out of an investigative sample of 38 residents (Residents #176, #247, & #285)

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from the facility did not ensure that a resident's assessment was accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment inaccurately documented that a resident received insulin injections. This was evident for 1 out of 1 resident reviewed for Resident Assessment out of an investigative sample of 38 residents. (Resident #194)

Inspectors wroteBased upon observation, interview, and record review, conducted during the Recertification survey, the facility did not ensure it provided an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 2 of 6 residents reviewed for Activities out of a sample of 38 residents. (#209 and #224) The finding is: The facility policy & procedure titled Sensory Program/Live Music Program created 1/27/21, documented the Recreation department has a sensory cart that travels from unit to unit designed specifically to work with those residents who have dementia or other condition which limits the cognitive ability. [...]

Inspectors wroteBased on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that it maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections was maintained. Specifically, (1) a resident with an indwelling catheter was noted to have the urine collection bag touching the floor or floor mat, and (2) a resident receiving oxygen therapy via nasal cannula tube was observed with tubing on the floor. This was evident for 2 random infection control observations on 2 out of 8 resident units. (Unit 2 and Unit 4) The finding is: [...]