Inspection Reports for Hillside Manor Nursing Home
1109 E National Hwy, Washington, IN 47501, IN, 47501
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 25, 2025 found no deficiencies related to the complaint investigated at that time. Earlier inspections showed a mixed record, with several surveys citing deficiencies in areas such as care planning, medication management, infection control, environmental sanitation, and emergency preparedness. Complaint investigations were mostly unsubstantiated, though some substantiated complaints resulted in citations for issues like unsanitary conditions, medication misappropriation, and inadequate behavioral health care. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements recently, with the last two inspections showing compliance after previous citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
193% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
36 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454222.
Complaint Details
Complaint IN00454222 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00454222 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 36
Medicaid residents: 35
Other residents: 1
Inspection Report
Re-Inspection
Census: 33
Capacity: 33
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-09-04, including a PSR to the Investigation of three complaints.
Complaint Details
The visit included investigations of Complaint IN00440429, Complaint IN00438183, and Complaint IN00437376, all of which were corrected.
Findings
Hillside Manor Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of the three complaints, all of which were corrected.
Report Facts
Census Bed Type: 33
Census Payor Type: 33
Inspection Report
Re-Inspection
Census: 30
Capacity: 48
Deficiencies: 0
Date: Nov 8, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/17/24 was performed to verify compliance with life safety code requirements.
Findings
At this PSR to the Life Safety Code survey, Hillside Manor Nursing Home was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Facility capacity: 48
Census: 30
Inspection Report
Life Safety
Census: 30
Capacity: 48
Deficiencies: 2
Date: Sep 17, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 09/17/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain one of nine battery powered emergency lights, and failure to ensure the emergency generator display panel was in proper operating condition.
Deficiencies (2)
Failed to ensure 1 of 9 battery powered emergency light sets was maintained in accordance with Life Safety Code 7.9.
Failed to ensure the display panel for 1 of 1 emergency generator was in proper operating condition, with multiple caution lights flashing.
Report Facts
Battery powered emergency lights: 9
Certified beds capacity: 48
Census: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Chapman | HFA | Laboratory Director's or Provider/Supplier Representative's signature on the report. |
| Maintenance Supervisor | Interviewed and acknowledged deficiencies related to emergency lights and generator. | |
| Administrator | Participated in exit conference reviewing findings. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 15
Date: Sep 4, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00434339, IN00440429, IN00438183, and IN00437376.
Complaint Details
The visit included investigation of complaints IN00434339, IN00440429, IN00438183, and IN00437376. Deficiencies related to complaints IN00440429, IN00438183, and IN00437376 were cited at F921.
Findings
Multiple deficiencies were cited including failure to ensure residents' rights in care planning, inaccurate MDS assessments, incomplete care plans, ineffective pressure ulcer prevention, unsafe medication storage, inadequate infection control practices, and environmental safety issues.
Deficiencies (15)
Failed to ensure residents' right to participate in person-centered care plans related to narcotic use.
Failed to determine clinical appropriateness of resident self-administration of medications.
Failed to ensure accurate Minimum Data Set (MDS) assessments for residents on antiplatelet medication, diuretics, and oxygen.
Failed to develop and implement comprehensive person-centered care plans for residents on various medications and oxygen.
Failed to maintain timely and revised comprehensive care plans including fall interventions and medication changes.
Failed to provide effective services to prevent development of pressure ulcers for a resident at risk.
Failed to ensure residents receive adequate supervision and assistive devices to prevent accidents related to possession of vapes.
Failed to provide respiratory care in accordance with professional standards including oxygen orders, tubing changes, and filter cleaning.
Failed to maintain safe and secure storage of medications including labeling opened medications and completing refrigerator temperature logs.
Failed to ensure a safe, sanitary, and homelike environment including maintenance and cleaning of restrooms, shower rooms, furniture, and doors.
Failed to maintain an effective pest control program to keep the facility free of pests and rodents.
Failed to develop, implement, and maintain an effective training program for all staff based on resident population needs including PTSD and substance abuse.
Failed to maintain complete and accurate clinical record documentation for hospitalizations and skin conditions.
Failed to ensure infection prevention and control practices including glove use, hand hygiene, resident care, and Enhanced Barrier Precautions.
Failed to designate a certified Infection Preventionist with specialized training and dedicated time for infection control duties.
Report Facts
Residents reviewed for narcotic use: 32
Residents reviewed for MDS assessments: 14
Residents reviewed for care plans: 6
Residents reviewed for respiratory care: 5
Residents reviewed for medication administration: 6
Residents reviewed for infection control: 6
Residents reviewed for accidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 13 | Licensed Practical Nurse | Named in respiratory care, infection control, and clinical record documentation findings |
| RN 5 | Registered Nurse | Named in respiratory care and medication cart findings |
| DON | Director of Nursing | Named in multiple findings including respiratory care, infection control, and facility assessment |
| Administrator | Named in multiple findings including complaint investigation, facility assessment, and infection control | |
| CNA 9 | Certified Nurse Aide | Named in infection control and resident care observations |
| CNA 7 | Certified Nurse Aide | Named in infection control and resident care observations |
| PCA 17 | Personal Care Attendant | Named in infection control and resident care observations |
| Dietary Manager | Named in kitchen sanitation findings | |
| Housekeeper 35 | Named in laundry handling findings | |
| SSD | Social Services Director | Named in infection control and training findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 28, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00430598 Survey with unrelated deficiencies ending March 22, 2024.
Complaint Details
Investigation of Complaint IN00430598; paper compliance review.
Findings
Hillside Manor was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Investigation of Complaint IN00430598 Survey and unrelated deficiencies.
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 2
Date: Mar 22, 2024
Visit Reason
This visit included the investigation of Complaint IN00430598. The complaint was related to behavioral health services and elopement concerns for a resident.
Complaint Details
Complaint IN00430598 was investigated with no deficiencies related to the allegations cited. However, unrelated deficiencies were cited regarding behavioral health services and medical record documentation.
Findings
The facility failed to provide sufficient behavioral health care for one resident who eloped from the facility unwitnessed and failed to maintain complete and accurate medical records for two residents, including lack of documentation of the elopement and wound treatment orders.
Deficiencies (2)
Failed to provide sufficient behavioral health care for a resident who eloped from the facility unwitnessed.
Failed to maintain complete and accurate medical records for two residents, including lack of documentation of elopement and wound treatment.
Report Facts
Census: 34
Total Capacity: 34
Incident Date: Feb 25, 2024
Medication Dosage: 2
Deficiency Count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Chapman | HFA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| DON | Director of Nursing | Interviewed regarding resident elopement and medical record documentation |
| Facility Administrator | Interviewed regarding resident behavior incident | |
| QMA 6 | Interviewed regarding resident exit seeking behavior | |
| RN 4 | Registered Nurse | Interviewed regarding wound treatment documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 13, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00423266, IN00423056, and IN00421327 survey ending December 15, 2023.
Complaint Details
Investigation of Complaints IN00423266, IN00423056, and IN00421327; paper compliance review found facility in compliance.
Findings
Hillside Manor was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigations.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
This visit included the investigation of complaints IN00423266, IN00423056, IN00421327, and IN00419579 at Hillside Manor Nursing Home.
Complaint Details
Complaints IN00423266, IN00423056, and IN00421327 were substantiated with federal/state deficiencies cited at F921. Complaint IN00419579 had no deficiencies related to the allegations.
Findings
The facility failed to ensure a safe, sanitary, and homelike environment in resident rooms and shared shower rooms, with issues including excessively hot water temperatures, unclean restrooms, damaged flooring, leaking plumbing, and inadequate cleaning schedules. Corrective actions were implemented including replacing fixtures, adjusting water heaters, and updating cleaning schedules.
Deficiencies (1)
Failed to ensure a safe, sanitary, and homelike environment in resident rooms and shared shower rooms, including water temperatures being too high, unclean restrooms, damaged flooring, leaking plumbing, and soap dispenser issues.
Report Facts
Census: 35
Water temperature: 140
Deficiency completion date: Jan 4, 2024
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Chapman | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance 4 | Interviewed regarding water heaters and temperature adjustments | |
| Housekeeper 6 | Interviewed regarding housekeeping staffing and cleaning duties | |
| Facility Administrator | Provided facility policies and schedules related to water temperature and housekeeping |
Inspection Report
Re-Inspection
Census: 35
Capacity: 48
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 10/10/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to provide a hard packed all-weather travel surface at one courtyard gate exit discharge area. This deficiency could affect at least 10 residents, staff, and visitors.
Deficiencies (1)
Failed to ensure 1 of 1 courtyard gate exit discharge area was provided with a hard packed all-weather travel surface.
Report Facts
Facility capacity: 48
Census: 35
Residents potentially affected: 10
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey ending September 22, 2023.
Findings
Hillside Manor Nursing Home was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure survey.
Inspection Report
Routine
Census: 35
Capacity: 48
Deficiencies: 16
Date: Oct 10, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with emergency preparedness, fire safety, and related regulatory requirements.
Findings
The facility was found not in compliance with emergency preparedness exercise requirements, generator maintenance and testing, fire safety door integrity, fire alarm system testing, portable fire extinguisher inspections, electrical safety including GFCI protection and receptacle testing, and proper storage of oxygen cylinders. Several deficiencies were noted including failure to conduct required emergency preparedness exercises, incomplete generator maintenance records, unsecured oxygen cylinders, and missing fire extinguisher inspection tags.
Deficiencies (16)
Failed to conduct emergency preparedness exercises at least twice per year including unannounced staff drills.
Failed to maintain and provide documentation of routine maintenance and testing of emergency generator.
Egress courtyard gate equipped with a non-visible latch requiring special manipulation to open.
Basement stairway door did not latch properly into its frame.
Pantry/food storage room door held open with jugs preventing self-closing.
Kitchen exhaust system inspection not performed semiannually as required.
Failed to ensure smoke detector sensitivity testing was performed within the past 24 months.
Failed to provide documentation of semi-annual visual inspection of fire alarm system devices.
Portable fire extinguisher in main dining room missing monthly inspection tag.
Corridor door to kitchen had holes compromising smoke resistance.
Two wet location electrical receptacles had open ground and did not break circuit on GFCI testing.
Electrical receptacle in middle hall had a loose cover plate with exposed gap.
Multi-plug adapter used in resident room 12A as substitute for fixed wiring.
Oxygen cylinders in resident room 9 were unsecured and freestanding on the floor.
Failed to ensure annual testing documentation for all non-hospital grade electrical receptacles in resident rooms.
Failed to provide documentation of a four hour emergency generator test within past 36 months.
Report Facts
Facility capacity: 48
Facility census: 35
Deficiencies cited: 16
Emergency generator run test duration: 4
Fire extinguisher monthly inspections missing: 1
Electrical receptacles tested: 235
Oxygen cylinders unsecured: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Myers | Local Emergency Planning Director | Contacted to coordinate community based emergency preparedness exercises |
| Julie Chapman | HFA | Facility Administrator present during survey and exit conference |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 6
Date: Sep 22, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00415901.
Complaint Details
Complaint IN00415901 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in several areas including failure to ensure residents' right to self-administer medications with proper physician orders, inaccurate Minimum Data Set (MDS) assessments, failure to obtain physician's orders for oxygenation, significant medication administration errors, failure to submit complete Payroll-Based Journal (PBJ) staffing data, and inadequate infection control practices during perineal care.
Deficiencies (6)
Failure to ensure residents that were self-administering medications were assessed for capability and had a physician's order to self-administer medications (Resident 18).
Failure to ensure accurate Minimum Data Set (MDS) assessments reflecting residents' status, including medication administration and assistance levels (Residents 4, 9, 13, 17, 29, 30, 35, and 39).
Failure to obtain a Physician's Order for oxygenation for Resident 18.
Failure to ensure residents were free of significant medication errors; nurse failed to prime insulin pen before administration (Resident 139).
Failure to submit complete direct care staffing data to the Payroll-Based Journal (PBJ) system for the period April 1, 2023 through June 30, 2023.
Failure to follow infection control practices during perineal care; gloves were not changed between dirty and clean tasks and hand hygiene was not performed appropriately (Residents 4, 17, and 35).
Report Facts
Census: 37
Survey dates: September 18, 19, 20, 21, 22, 2023
Medication administration errors: 7
Insulin units: 10
PBJ reporting period: April 1, 2023 through June 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Chapman | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| RN 10 | Registered Nurse | Named in findings related to medication administration errors and oxygen order deficiency |
| CNA 28 | Certified Nursing Aide | Named in infection control deficiency during perineal care observations |
| CNA 35 | Certified Nursing Aide | Named in infection control deficiency during perineal care observations |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Jun 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410672 regarding federal/state deficiencies related to allegations of unsanitary conditions in shared resident restrooms.
Complaint Details
Complaint IN00410672 was substantiated with federal/state deficiencies cited at F921 related to unsanitary conditions in shared resident restrooms.
Findings
The facility failed to ensure a sanitary, homelike environment in 4 of 5 shared resident restrooms, with observations of unclean conditions, uncovered personal items, damaged restroom fixtures, and inconsistent cleaning schedules. Corrective actions including a new cleaning schedule, staff inservice, and restroom renovations were implemented.
Deficiencies (1)
Facility failed to ensure a sanitary, homelike environment in 4 of 5 shared resident restrooms, including unclean conditions, uncovered toothbrushes, brown splatter marks, uncovered bed pans, overflowing trash, damaged flooring, and missing toilet paper holders.
Report Facts
Census: 38
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Chapman | HFA | Facility representative signing the report |
| Housekeeper 2 | Interviewed regarding cleaning schedules and practices | |
| Facility Administrator | Interviewed regarding environment policy and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 27, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00410672 survey ending June 27, 2023.
Complaint Details
Investigation of Complaint IN00410672; paper compliance review found the facility in compliance.
Findings
Hillside Manor Nursing Home was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Inspection Report
Complaint Investigation
Census: 36
Capacity: 36
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
The visit was conducted to investigate complaints IN00409052 and IN00407013 at Hillside Manor Nursing Home.
Complaint Details
Investigation of Complaints IN00409052 and IN00407013 found no deficiencies related to the allegations.
Findings
No deficiencies were cited related to the allegations in both complaints. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 36
Total Capacity: 36
Medicare Residents: 1
Medicaid Residents: 31
Other Payor Residents: 4
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
The visit was conducted to investigate Complaint IN00405603 at Hillside Manor Nursing Home.
Complaint Details
Complaint IN00405603 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies were cited related to the complaint allegation. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 33
Census Bed Type - SNF: 3
Census Bed Type - SNF/NF: 30
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00391757.
Complaint Details
Investigation of Complaint IN00391757; paper compliance review found facility in compliance.
Findings
Hillside Manor Nursing Home was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Jan 3, 2023
Visit Reason
The visit was conducted to investigate three complaints (IN00397406, IN00391757, and IN00395159) regarding the facility.
Complaint Details
Complaint IN00397406: Substantiated with no deficiencies cited. Complaint IN00391757: Substantiated with deficiencies cited at F602 related to medication misappropriation. Complaint IN00395159: Substantiated with no deficiencies cited.
Findings
The investigation substantiated complaint IN00391757 with federal/state deficiencies cited related to medication misappropriation involving two residents. A staff member admitted to stealing residents' gabapentin medication. Complaints IN00397406 and IN00395159 were substantiated but no deficiencies were cited related to those allegations.
Deficiencies (1)
Facility failed to ensure residents were free from misappropriation of medication; a staff member confessed to stealing residents' gabapentin medication.
Report Facts
Residents reviewed for medication misappropriation: 4
Residents affected by misappropriation: 2
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 13 | Licensed Practical Nurse | Confessed to stealing residents' gabapentin medication; tested positive for gabapentin without prescription; terminated for inappropriate behavior. |
| Julie Chapman | HFA (Health Facility Administrator) | Provided statements and information regarding the investigation and corrective actions. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 27, 2022
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00372263, IN00382034, and IN00385282, including review of the Focused Infection Control Survey ending on July 26, 2022.
Complaint Details
The visit was related to investigations of complaints IN00372263, IN00382034, and IN00385282. Compliance was found in the paper review.
Findings
Hillside Manor was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the investigations and the Focused Infection Control survey.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Jul 25, 2022
Visit Reason
The visit included investigation into complaint allegations IN00372263, IN00382034, and IN00385282, as well as a COVID-19 Focused Infection Control survey.
Complaint Details
The complaint allegations IN00372263, IN00382034, and IN00385282 were substantiated with federal/state deficiencies cited at F812, F880, and F921 respectively.
Findings
The facility was found to have multiple deficiencies including failure to store food according to food safety standards, failure to maintain infection control practices including improper handwashing and mask use, lack of a comprehensive COVID-19 vaccination policy for staff including contingency plans for unvaccinated staff, and unsanitary conditions in the laundry area with standing water and resident clothing exposed to water.
Deficiencies (4)
Food was stored in refrigerators and freezers not labeled and/or dated, and was open to air.
Facility failed to maintain infection control practices to mitigate the spread of COVID-19, including improper handwashing and improper N95 mask use.
Facility failed to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19, lacking contingency plans for unvaccinated staff.
Facility failed to ensure a sanitary, homelike environment in the lower level laundry area; standing water was observed with bags of resident clothing and linens laying on the floor in the water.
Report Facts
Census: 40
Deficiencies cited: 4
Survey date: Jul 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Named in infection control finding related to improper N95 mask use and handwashing | |
| CNA 5 | Named in infection control finding related to handwashing | |
| ADON | Assistant Director of Nursing | Provided interviews and facility policies related to infection control and COVID-19 vaccination |
| Cook 6 | Interviewed regarding food labeling and dating | |
| Laundry Aide 2 | Interviewed regarding standing water in laundry area | |
| Facility Administrator | Provided interview and facility COVID-19 vaccination policy |
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