Hillside Rehab & Care Center

In the surveyor’s words

From the most serious findings on record at Hillside Rehab & Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Nov 17, 2023

  Based on observation, interview, and record review, the facility failed to ensure a female resident was protected from another resident who has a known history of sexual abuse. This failure resulted in the resident entering the room of another female resident, then touching her breasts and face and kissing her. This applies to 1 of 4 residents (R1) reviewed for sexual abuse in a sample of 5. This has the potential to affect all 24 female residents (R1, R3-R25) residing in the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 10/31/23 at 4:00 AM when R2, who has a history of sexual abuse, entered R1's room and put his hands down her gown and touched her breasts. […]

• Actual harm, isolatedF689Aug 19, 2026

  Based on interview and record review, the facility failed to provide and maintain an appropriate size wheelchair for resident's body habitus and condition.This failure resulted in R1 sustaining a 5.5cm (centimeter) by 7cm skin tear to her right lower abdomen during transfer/repositioning that required closure with 9 sutures/stitches in Emergency Department.This applies to 1 resident (R1) reviewed for accidents in a sample of 4.The findings include:R1's Face sheet shows the following diagnoses: congestive heart failure, morbid severe obesity, type 2 diabetes mellitus, edema, pressure ulcer of right buttock and pressure ulcer of sacral region. […]

• Actual harm, isolatedF689Jan 8, 2026

  Based on observation, interview and record review the facility failed to ensure residents who were high risk for falls were supervised to prevent falls. These failures resulted in R1 & R3 falling being sent to the hospital and sustaining fractures. This applies to 2 of 3 residents (R1 & R3) reviewed for safety/supervision in the sample of 5. The findings include:1. R1's face sheet lists his diagnoses to include: congestive heart failure, shortness of breath, Type 2 diabetes mellitus, morbid obesity, anxiety disorder and wedge compression fracture of first lumber vertebra. On 1/7/26 at 9:57 AM, R1 was sitting in his wheelchair in his room. He stated, he had pain in his back. This surveyor asked him why what happened? He stated, he had a fall and hurt his back. […]

• Actual harm, isolatedF686Jun 18, 2025

  Based on observation, interview, and record review, the facility failed to follow the nurse practitioner's orders to consult a wound care doctor for treatment of a new acquired wound. The facility also failed to reposition a resident who was at risk for pressure ulcers. This applies to 2 of 3 residents (R1 and R8) reviewed for pressure ulcers in the sample of 8. This failure resulted in the R1's wounds declining, enlarging and developing into full thickness injuries. The findings include: 1. R1's electronic medical record showed R1 was originally admitted to the facility on [DATE]. R1's medical record also showed he was discharged to the hospital on May 21, 2025 and readmitted to the facility on [DATE]. […]

• Actual harm, isolatedF692Oct 28, 2021

  Based on observation, interview, and record review, the facility failed to assess nutritional needs on admission, follow recommendations for monitoring daily weights and provide nutrition supplement to a resident with high nutrition risk and weight loss. This resulted in R233 losing 7.4% (10.6 pounds) weight in 13 days. This applies to 1 of 2 residents (R233) reviewed for nutrition in the sample of 13. The findings include: R233's EHR (electronic health record) included that R233 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R233's MDS (minimum data set) dated 10/26/21 included that R233 was cognitively intact. R233's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same POS included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]