Hillside Medical Lodge

Inspectors wroteBased on interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for three (Residents #16, #28, and #91) of eight residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident Residents #16's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). 2. The facility failed to ensure Resident Residents #28's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on a BiPAP (bilevel positive airway pressure: normalizes breathing by delivering pressurized air into the upper airway leading into the lungs). 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Residents #28, #46, and #91) of twelve residents reviewed for respiratory care. 1. The facility failed to ensure Resident #28's mask for BiPAP (bilevel positive airway pressure: normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) was properly stored when not in use on 12/09/2025. 2. The facility failed to ensure Resident #46's breathing mask was properly stored when not in use on 12/09/2025. 3. The facility failed to ensure Resident Residents #91's CPAP (continuous positive airway pressure: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #80) of eighteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident 80's room was in a position that was accessible to the resident on 12/09/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for one (Resident #84's) of ten residents reviewed for privacy and confidentiality. The facility failed to ensure LVN B would not disclose Resident #84's medical treatment to her roommate on 12/09/25. This failure could place the residents at risk of their medical information or treatment being disclosed to unauthorized individuals.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop a complete care plan that meets all of a resident's needs, with timeframes and actions that can be measured for two (Resident #28 and #91) of twelve residents reviewed for care plans. 1. The facility failed to ensure Resident #28 was care planned for a BiPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) on 12/09/2025. 2. The facility failed to ensure Resident #91 was care planned for a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) on 12/09/2025. These failures could place the residents at risk of not receiving the necessary care and services required.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #8) of two residents reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure LVN D would flush the g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) before administering medications and flush after with the amount indicated in the physician order on 12/10/2025. This failure could place residents with g-tubes at risk for blockage, aspiration, discomfort, and overhydration.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one (Resident #100) of twenty residents reviewed for pharmaceutical services. The facility failed to ensure MA J did not leave Resident #100's Arginine inside the room for the resident to take by herself on 12/09/2025. This failure could place residents at risk of not receiving medications as ordered, potential overdose, and adverse effects.

Inspectors wroteBased observation, interview, and record review the facility failed to establish and maintain 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 for two (Resident #8 and Resident 100) of twelve residents reviewed for infection control. 1. The facility failed to ensure CNA F and CNA G wore gowns and gloves while transferring Resident #8, who had a g-tube, on 12/10/2025. 2. The facility failed to ensure LVN C performed hand hygiene while connecting Resident #100's IV on 12/09/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 4 Residents (Resident #1) reviewed for pharmaceutical services. MA A administered a non-prescribed 5 MG of Buspirone (a medication for anxiety) and non-prescribed 400 MG of Magnesium Oxide (a medication for heartburn, sour stomach, or acid indigestion) to R #1 on 11/14/2024. The noncompliance began on 11/14/2024 and ended on 11/14/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at the facility at risk of medication errors.

Inspectors wroteBased on observations, interviews, and record review , the facility failed to provide sufficient support personnel with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 5 (Dietary A, Dietary B, Dietary C, Dietary D, and Dietary E) of 9 dietary staff. The facility did not ensure 5 (Dietary A, Dietary B, Dietary C, Dietary D, and Dietary E) of 9 dietary staff had a current food handler's certificate from the date of hire until August 13, 2024 . This failure could place all residents who consumed food prepared from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to ensure Dietary Aide C served food in accordance with professional standards and facility policy. These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to help prevent the development and transmission of communicable disease and infections on 2 of 3 ice chest observed for infection control. Ice chest on hall 100 revealed plastic cup stored inside laying on the ice. Ice chest on hall 400 revealed metal scoop inside laying on the ice. This failure placed residents at risk for cross contamination and/or spread of infection that could cause severe illness and decreased quality of life. Observation on 9/18/23 at 08:59 am of ice chest on hall 100 revealed Large Plastic cup inside lying on the ice. No storage container visible on ice chest. Observation on 9/18/23 at 09:17 am of ice chest on hall 400 revealed metal scoop inside lying on the ice. Scoop holder was attached to cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #24)7 residents reviewed for care plans. The care plans for Residents #24 failed to address her dementia diagnosis and what services would be provided to maintain the resident's needs These failures could affect residents by placing them at risk for not receiving care and services to meet their needs.