Deficiency Records for Hillside Heights Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Hillside Heights Rehabilitation 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-07 | 2024-01-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-07 | 2024-01-16 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-24 | 2023-05-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-24 | 2023-05-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-24 | 2023-05-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-24 | 2023-05-09 | 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 | 2023-03-24 | 2023-05-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-24 | 2023-05-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-24 | 2023-05-09 | 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 | 2023-03-24 | 2023-05-09 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-03-24 | 2023-05-09 | N |
| 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 | 2023-03-24 | 2023-05-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-03-24 | 2023-05-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-24 | 2023-05-09 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-03-24 | 2023-05-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-24 | 2023-05-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-24 | 2023-05-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-24 | 2023-05-09 | Y |
| Provide appropriate foot care. | Health | 2023-03-24 | 2023-05-09 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-21 | 2023-05-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-21 | 2023-05-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-21 | 2023-05-09 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2022-02-23 | 2022-04-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-04 | 2022-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-04 | 2022-04-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-04 | 2022-04-07 | 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 | 2022-03-04 | 2022-04-07 | 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 | 2022-03-04 | 2022-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-04 | 2022-04-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-23 | 2022-04-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-23 | 2022-04-07 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-02-23 | 2022-04-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-23 | 2022-04-07 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-02-23 | 2022-04-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-17 | 2022-02-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-17 | 2022-02-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-17 | 2022-02-01 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-06-24 | 2021-08-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-24 | 2021-08-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-24 | 2021-08-09 | Y |
| 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 | 2018-12-14 | 2019-03-06 | 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 | 2018-12-14 | 2019-01-18 | N |
| Respond appropriately to all alleged violations. | Health | 2018-12-14 | 2019-01-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-14 | 2019-01-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-14 | 2019-01-18 | N |
| Post nurse staffing information every day. | Health | 2018-12-14 | 2019-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-14 | 2019-01-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-12-14 | 2019-01-18 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-12-18 | 2019-01-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-12-18 | 2019-01-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-12-18 | 2019-01-18 | N |
