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Deficiency Records for Hillside Manor Nursing Home
A list of the most recent deficiencies for Hillside Manor Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Hillside Manor Nursing Home. 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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-04 | 2024-10-14 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-09-04 | 2024-09-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-09-04 | 2024-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-09-04 | 2024-09-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-04 | 2024-09-30 | 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 | 2024-09-04 | 2024-09-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-04 | 2024-09-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-09-04 | 2024-09-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-04 | 2024-09-30 | 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 | 2024-09-04 | 2024-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-04 | 2024-09-30 | 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 | 2024-09-04 | 2024-09-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-09-04 | 2024-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-04 | 2024-09-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-09-04 | 2024-09-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-09-04 | 2024-09-30 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-09-04 | 2024-09-30 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-09-04 | 2024-09-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-09-17 | 2024-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-17 | 2024-09-30 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-03-22 | 2024-04-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-22 | 2024-04-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-15 | 2024-01-04 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-10-10 | 2023-11-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| 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 | 2023-10-10 | 2023-11-07 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-22 | 2023-10-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-22 | 2023-10-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-22 | 2023-10-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-22 | 2023-10-18 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-09-22 | 2023-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-10-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-27 | 2023-07-12 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-04 | 2023-01-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-26 | 2022-08-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-26 | 2022-08-15 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-26 | 2022-08-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-26 | 2022-08-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-16 | 2021-10-07 | 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 | 2021-08-16 | 2021-10-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-16 | 2021-10-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-16 | 2021-10-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-16 | 2021-10-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-16 | 2021-10-07 | 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 | 2021-08-16 | 2021-10-07 | N |
| Post nurse staffing information every day. | Health | 2021-08-16 | 2021-10-07 | 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 | 2021-08-16 | 2021-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-16 | 2021-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-16 | 2021-10-07 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Develop a communication plan. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Meet other general requirements. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| 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 | 2021-09-01 | 2021-09-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-08-16 | 2021-09-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-08-16 | 2021-09-06 | N |
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