Deficiency Records for Hillside Rehab and Healthcare Center
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 | 2023-08-01 | 2023-08-03 | Y |
| 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 | 2023-03-30 | 2023-04-18 | Y |
| 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 | 2023-03-30 | 2023-04-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-30 | 2023-04-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-30 | 2023-04-18 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-03-30 | 2023-04-18 | Y |
| 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 | 2023-01-18 | 2023-04-18 | Y |
| 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 | 2023-01-18 | 2023-04-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-18 | 2023-04-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-18 | 2023-04-18 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-01-18 | 2023-04-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-18 | 2023-03-28 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-02-23 | 2023-03-23 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-02-23 | 2023-03-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-01-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-28 | 2022-11-29 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-10-28 | 2022-11-29 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-28 | 2022-11-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-15 | 2022-10-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-15 | 2022-10-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-10-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-15 | 2022-10-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-22 | 2022-10-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-22 | 2022-10-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-22 | 2022-10-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-22 | 2022-10-19 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-15 | 2022-09-15 | Y |
| 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 | 2022-06-22 | 2022-09-15 | Y |
| 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 | 2022-08-15 | 2022-08-29 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-06-22 | 2022-08-03 | Y |
| 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 | 2022-05-02 | 2022-05-09 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-05-02 | 2022-05-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-25 | 2022-03-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-25 | 2022-03-10 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-01-25 | 2022-03-10 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-01-25 | 2022-03-10 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-01-25 | 2022-03-10 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-01-25 | 2022-03-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-25 | 2022-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-25 | 2022-03-10 | N |
| Provide activities to meet all resident's needs. | Health | 2022-01-25 | 2022-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-25 | 2022-03-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-25 | 2022-03-10 | 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 | 2022-01-25 | 2022-03-10 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-01-25 | 2022-03-10 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-01-25 | 2022-03-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-25 | 2022-03-10 | Y |
| 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 | 2022-01-25 | 2022-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-25 | 2022-03-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-01-25 | 2022-03-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-25 | 2022-03-10 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-25 | 2022-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-24 | 2020-02-11 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-12-24 | 2020-01-28 | 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 | 2019-12-24 | 2020-01-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-24 | 2020-01-28 | 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 | 2019-12-24 | 2020-01-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-24 | 2020-01-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-12-24 | 2020-01-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-24 | 2020-01-28 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-12-24 | 2020-01-28 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-12-24 | 2020-01-28 | N |
| Provide activities to meet all resident's needs. | Health | 2019-12-24 | 2020-01-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-24 | 2020-01-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-24 | 2020-01-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-24 | 2020-01-28 | 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 | 2019-12-24 | 2020-01-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-24 | 2020-01-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-24 | 2020-01-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-12-24 | 2020-01-28 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-12-24 | 2020-01-28 | 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 necessary and PRN use is limited. | Health | 2019-12-24 | 2020-01-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-24 | 2020-01-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-12-24 | 2020-01-28 | 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 | 2019-12-24 | 2020-01-28 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-12-24 | 2020-01-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-12-24 | 2020-01-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-24 | 2020-01-28 | N |
| Keep all essential equipment working safely. | Health | 2019-12-24 | 2020-01-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-12-24 | 2020-01-28 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-12-24 | 2020-01-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-24 | 2020-01-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-24 | 2020-01-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-12-24 | 2020-01-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-24 | 2020-01-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-24 | 2020-01-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-24 | 2020-01-28 | N |
| 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 |
| 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 care and assistance to perform activities of daily living for any resident who is unable. | 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 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | 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 necessary and PRN use is limited. | 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 |
| 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 requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | 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 |
