Deficiency Records for Hillside Rehab and Healthcare Center
Updated as of April 01, 2019
This is not the most recent data for Hillside Rehab and Healthcare Center. For the most recent information, click here.
A list of the most recent deficiencies for Hillside Rehab and Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-11-13 | 2019-02-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Have an externally vented heating system. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-13 | 2019-01-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-13 | 2019-01-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-11-13 | 2019-01-11 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-11-13 | 2019-01-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-11-13 | 2019-01-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-11-13 | 2019-01-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-11-13 | 2019-01-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-11-13 | 2019-01-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-13 | 2019-01-11 | N |
| Respond appropriately to all alleged violations. | Health | 2018-11-13 | 2019-01-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-13 | 2019-01-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-11-13 | 2019-01-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-13 | 2019-01-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-11-13 | 2019-01-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-11-13 | 2019-01-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-13 | 2019-01-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-13 | 2019-01-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-11-13 | 2019-01-11 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-11-13 | 2019-01-11 | N |
| Provide activities to meet all resident's needs. | Health | 2018-11-13 | 2019-01-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-11-13 | 2019-01-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-13 | 2019-01-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-11-13 | 2019-01-11 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-11-13 | 2019-01-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-11-13 | 2019-01-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-13 | 2019-01-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2018-11-13 | 2019-01-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-13 | 2019-01-11 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-11-13 | 2019-01-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-11-13 | 2019-01-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-13 | 2019-01-11 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-11-13 | 2019-01-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-13 | 2019-01-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-13 | 2019-01-11 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-01-30 | 2018-03-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-30 | 2018-03-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-01-30 | 2018-03-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-01-30 | 2018-03-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-30 | 2018-03-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-30 | 2018-03-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-01-30 | 2018-03-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-01-30 | 2018-03-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-01-30 | 2018-03-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-01-30 | 2018-03-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-01-30 | 2018-03-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-30 | 2018-03-26 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-01-30 | 2018-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-30 | 2018-03-26 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2018-01-30 | 2018-03-26 | N |
| Respond appropriately to all alleged violations. | Health | 2018-01-30 | 2018-03-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-01 | 2017-08-22 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-06-23 | 2017-08-22 | Y |
| Maintain comfortable and safe temperature levels. | Health | 2017-06-23 | 2017-08-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-06-23 | 2017-08-22 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-03-01 | 2017-04-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-03-01 | 2017-04-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-03-01 | 2017-04-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-03-01 | 2017-04-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-03-01 | 2017-04-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-03-01 | 2017-04-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-03-01 | 2017-04-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-03-01 | 2017-04-10 | N |
| 1) Protect current or future residents from giving up their Medicaid or Medicare benefits; or 2) follow federal rules for admissions. | Health | 2017-03-01 | 2017-04-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-03-01 | 2017-04-10 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-03-01 | 2017-04-10 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-03-01 | 2017-04-10 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-01 | 2017-04-10 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-01 | 2017-04-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-01 | 2017-04-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-03-01 | 2017-04-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-11-08 | 2016-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-09-09 | 2016-12-05 | Y |
