Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillside Plaza during CMS and state inspections, most recent first.
A resident with multiple complex conditions did not have medication administration consistently documented in the MAR, with numerous blank entries for various medications over two months. Nursing staff later confirmed they had administered the medications but failed to sign off at the time, only completing documentation after being prompted by facility leadership. Facility policy requires immediate documentation after administration, which was not followed in these instances.
Surveyors found the kitchen unsanitary, with an empty soap dispenser at the hand washing station, dried food bits and spills on the floor, and grubby surfaces on equipment and counters. Dietary staff confirmed that cleaning had not been done as required, and the facility's policy called for regular cleaning and sanitizing of kitchen areas. All residents receiving meals from the kitchen were potentially affected.
A resident with severe cognitive impairment and immobility developed an open area on the right inner heel that was not identified or treated promptly due to missed weekly skin assessments and lack of communication among staff. The wound was only discovered during incontinence care, and documentation of required skin assessments was absent, despite records indicating they were completed. The facility's policy for daily skin visualization and risk assessment was not followed, leading to delayed recognition and treatment of the wound.
A resident with ESRD and multiple comorbidities did not receive immediate assessment or documentation of her dialysis access site for bleeding or complications upon return from dialysis. Despite physician orders and facility policy requiring post-dialysis evaluation, staff only checked the site later in the shift, and the required documentation was missing.
A resident with a history of atrial fibrillation and heart failure did not receive a scheduled dose of Flecainide Acetate because the medication could not be found in the med cart. An LPN was unable to administer the medication or recall if the cardiology service was contacted. The medication was later found in an inconspicuous location, but not in time for the scheduled administration. The resident was cognitively intact and required some assistance with daily activities.
A deficiency was found when an LPN failed to perform hand hygiene after picking up dropped medications from the floor and before administering replacement medications to a resident with multiple health conditions. Additionally, a CNA providing incontinence care to another resident placed soiled linens and briefs directly on the floor instead of in a proper container, leaving them there during care. Both actions were contrary to facility policy on infection prevention and control.
The facility failed to update care plans for two residents with new fall prevention interventions. A resident with kidney failure and CHF fell from bed, but recommended interventions like a floor mattress and safety checks were not added to the care plan. Another resident with breast cancer and diabetes fell, and despite refusing non-skid socks and call light use, the care plan was not updated with these refusals or a new tab alarm intervention. The facility's policy required care plan updates, but this was not followed.
The facility failed to implement fall prevention interventions for two residents, leading to deficiencies in their care. A resident experienced an unwitnessed fall due to missing interventions like a floor mattress and safety checks. Another resident lacked non-skid strips and had a walker out of reach, despite physician orders and care plan interventions. Staff confirmed these oversights, indicating a lapse in following the facility's fall prevention policy.
A facility failed to change a resident's oxygen tubing weekly as ordered by the physician. The resident, with a history of kidney failure, CHF, and stroke, required oxygen due to ineffective breathing patterns. Despite the care plan and physician's orders, the tubing was not changed for three weeks. A nurse confirmed the oversight, which was against the facility's policy.
A resident reported discomfort with incontinence care provided by a CNA, but the LTC facility failed to promptly report, investigate, and remove the CNA from duty as per their abuse policy. The facility did not notify the Ohio Department of Health or law enforcement immediately, and the investigation was delayed, leading to a deficiency.
A resident reported improper incontinence care by a male CNA, describing it as degrading. Despite the report, the facility delayed investigating and did not immediately remove the CNA from providing care, contrary to its abuse policy. The investigation was initiated weeks later after corporate involvement, revealing inconsistencies in handling the incident.
The facility's QAPI committee failed to meet quarterly with the required members, including the medical director or designee. A review of sign-in sheets showed that while the medical director attended a meeting in March, they or a designee were absent in June, and a nurse practitioner attended as a designee in August. The facility's policy did not specify required members, and the absence of documentation was confirmed by the Administrator. This deficiency was found during a complaint investigation.
A resident with multiple health conditions experienced a significant drop in blood pressure, but the LPN administered morning medications without notifying the physician or nurse practitioner. The nurse practitioner indicated that the low blood pressure required physician notification and potential medication adjustments. The facility's policy lacked specific guidelines on when to notify physicians, contributing to the oversight.
A facility failed to promptly report an allegation of staff-to-resident sexual abuse involving a resident with COPD, diabetes, and spinal stenosis. The incident occurred during incontinence care, and despite the resident's discomfort, the facility did not report the incident to the Ohio Department of Health, local police, or the resident's physician until weeks later. Interviews revealed discrepancies in handling the incident, with concerns about thoroughness due to the CNA's relation to the Administrator.
The facility failed to ensure call lights were within reach for two residents, both at risk for falls and dependent on staff for assistance. Observations revealed that one resident's call light was ten feet away on another bed, while another's was on a nightstand out of reach. Interviews confirmed these findings, violating the facility's policy.
A facility failed to administer oxygen per physician orders and lacked appropriate signage for oxygen use. A resident with COPD and CHF received 4.5 liters of oxygen instead of the ordered three liters. Additionally, there was no signage indicating oxygen use in the resident's room or the central supply room where oxygen cylinders were stored. The DON confirmed these discrepancies, which violated the facility's policy.
A facility failed to implement proper infection control measures, including the use of Enhanced Barrier Precautions (EBP) for a resident with a pressure wound. An LPN did not wear a gown during high-contact care and carried medications against her chest, risking cross-contamination. Additionally, a blood pressure monitor was not cleaned between uses on two residents, and a bedpan was stored unsanitarily on the floor. The facility lacked specific policies addressing these issues.
Failure to Timely Document Medication Administration
Penalty
Summary
The facility failed to ensure timely and accurate documentation of medication administration for one resident out of three reviewed. The resident in question had multiple complex diagnoses, including osteomyelitis, spinal cord injury, sepsis, and paraplegia, and was cognitively intact. Review of the resident's electronic Medication Administration Record (MAR) for July and August revealed numerous instances where medications were not signed as administered, leaving blank spaces for several medications across multiple dates. Further investigation showed that the corresponding printed MARs for July had manual initials added after the fact, and the electronic MARs for August were signed off electronically at a much later date. Interviews with nursing staff and facility leadership confirmed that medications had been administered but were not documented at the time of administration. Staff reported forgetting to sign off on the MARs and later completed the documentation after being approached by facility management. Facility policy requires that the individual administering medications must record the administration directly after giving the medication and review the MAR at the end of each pass to ensure all doses are documented. The policy also states that no staff should leave duty without recording all medication administrations. The failure to document medication administration as required by policy and professional standards led to the identified deficiency.
Unsanitary Kitchen Conditions and Inadequate Cleaning Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary kitchen environment, as required by professional standards and facility policy. During an inspection, the soap dispenser above the hand washing station was found to be empty, and a dietary aide indicated that housekeeping would need to refill it. Further observation of the kitchen revealed dried food bits and multiple dried, dark brown and clear, sticky fluid spills on the floor. Metal counters, meal carts, shelves, and the doors and sides of the freezer, cooler, and oven were covered with whitish drip marks and what appeared to be dried food and liquid smudges, making all surfaces appear grubby. Interviews with dietary staff confirmed the unsanitary conditions, with one aide stating she had just arrived for work and could tell that no cleaning had been done the previous day. The dietary manager, who had only recently started working at the facility, also confirmed the kitchen was not clean and acknowledged the need for improvement. Review of the facility's undated policy on food preparation and storage indicated that the kitchen was to be kept neat and orderly, with surfaces and equipment cleaned and sanitized as appropriate. All 43 residents who received meals from the kitchen had the potential to be affected by these unsanitary conditions.
Failure to Timely Identify and Treat Resident's Open Heel Wound
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, and total dependence for mobility and personal care developed an open area on the right inner heel that was not identified or treated in a timely manner. The resident's care plan included risk factors for skin breakdown and interventions such as regular Braden scoring and assistance with turning and repositioning, but did not specify weekly skin assessments or prompt reporting of skin abnormalities to a physician. Physician orders required weekly skin assessments, but documentation of these assessments was missing, despite the Treatment Administration Record indicating they were completed. Direct observation revealed the open area on the resident's right inner foot, which had a dark reddish-brown wound bed and clear tissue covering it. The CNA providing care was aware of the wound but did not report it, assuming nurses already knew. The LPN who observed the wound did not notify the assigned nurse. Further interviews with nursing staff and the DON confirmed that the assigned nurse and DON were unaware of the wound, and no one had communicated its presence. The wound was later assessed by the wound nurse practitioner, who described it as an abrasion with granulation tissue and mild maceration, and a treatment was subsequently initiated. Review of the resident's medical record, progress notes, and shower sheets showed no documentation of the wound or evidence that the required weekly skin assessments were performed. The facility's skin care policy required daily visualization of residents' skin and risk assessment using the Braden Scale, but these procedures were not followed for this resident, resulting in a failure to identify and treat the wound in a timely manner.
Failure to Immediately Assess Dialysis Access Site Post-Treatment
Penalty
Summary
The facility failed to ensure that a resident who was dependent on hemodialysis received comprehensive assessments of her dialysis access site immediately after returning from dialysis treatments. Review of the resident's medical record and dialysis communication forms over a period of several months showed no evidence of immediate monitoring or documentation of the access site for bleeding or other complications upon return from the dialysis center. Although physician orders required completion of dialysis assessment forms before and after dialysis, as well as shunt assessments every shift, there was no documentation that the access site was evaluated right after the resident's return to the facility. Interviews with the Director of Nursing and Clinical Service Manager confirmed that while nurses were checking the resident's shunt during the shift, there was no evidence of an immediate post-dialysis assessment as required. The facility's policy stated that the Dialysis Communication Form should be completed each time the resident had dialysis, but the form lacked documentation of the resident's status immediately after returning from treatment. The resident involved had multiple diagnoses, including end-stage renal disease, diabetes, and cardiac conditions, and required assistance with activities of daily living.
Missed Dose of Cardiac Medication Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident with a history of paroxysmal atrial fibrillation, pneumonia, and chronic diastolic heart failure did not receive a scheduled dose of Flecainide Acetate 50 mg, an antiarrhythmic medication ordered to be administered twice daily. The medication was not given as ordered on the evening of 03/11/25 because it could not be located in the medication cart. The nurse on duty was unable to find the medication, did not administer it, and could not recall if the resident's cardiology service was contacted. The nurse stated the medication was eventually found in an inconspicuous place in the cart, but not in time for the scheduled dose. Documentation indicated that the pharmacy was contacted after the missed dose, and the supervisor was notified, but the medication could not be reordered by the nurse at that time. The resident's care plan identified her as being at risk for decreased cardiac output and abnormal lab values related to her cardiac conditions, with interventions including medication administration as ordered and monitoring for cardiac symptoms. The resident was cognitively intact and required some assistance with activities of daily living. Interviews with staff confirmed the missed dose and the importance of the medication, although the nurse practitioner felt that missing a single dose would not likely cause immediate harm. The facility's review determined that only one dose was missed, and the medication was subsequently located.
Failure to Follow Infection Control Practices During Medication Administration and Incontinence Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control practices during medication administration for a resident with organ-limited amyloidosis, vascular dementia, and acute kidney failure. The LPN prepared the resident's medications, and when two pills were dropped on the floor, she picked them up with her bare hands and discarded them. Without performing hand hygiene, she proceeded to open the medication cart, prepare replacement medications, and administer them to the resident, all without washing her hands or using hand sanitizer at any point during the process. The LPN confirmed in an interview that she did not perform hand hygiene after handling the dropped pills or before handling the medication cart and administering the medications. Another deficiency was observed during incontinence care for a resident with anoxic brain damage, benign intracranial hypertension, hemiplegia, and hemiparesis, who was dependent on staff for all activities of daily living and was always incontinent. A Certified Nursing Assistant (CNA) providing care threw the resident's soiled bed linens, towels, and urine-saturated incontinence brief directly onto the floor instead of placing them in a plastic bag or appropriate container. The soiled items remained on the floor during care, and the CNA acknowledged in an interview that this action could cause cross contamination. Facility policy requires hand hygiene before and after direct resident contact, before handling medications, and after handling soiled linens, but these procedures were not followed.
Failure to Update Care Plans for Fall Interventions
Penalty
Summary
The facility failed to update care plans with new interventions for falls for two residents. Resident #1, who was admitted with conditions such as kidney failure and congestive heart failure, experienced an unwitnessed fall from bed. Although new interventions like placing a mattress on the floor and conducting 30-minute safety checks were recommended, these were not added to the resident's care plan. An observation confirmed the absence of the mattress in the resident's room, and the Director of Nursing acknowledged the oversight. Resident #29, with a history of breast cancer and diabetes, also experienced an unwitnessed fall. Despite multiple refusals to wear non-skid socks or use the call light, the care plan was not updated to reflect these refusals or the new intervention of adding a tab alarm while in bed. The facility's policy required care plans to be updated as needed, but this was not adhered to, as confirmed by the Administrator.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents, leading to deficiencies in their care. Resident #1, who was at risk for falls due to an unstable health condition, experienced an unwitnessed fall from bed. Despite recommendations from a fall review to place a mattress on the floor and conduct 30-minute safety checks, these interventions were not added to the resident's care plan, nor were they observed in practice. The Director of Nursing confirmed the absence of these interventions, indicating a lapse in updating the care plan and implementing necessary safety measures. Similarly, Resident #29, who had a history of falls and was at high risk, did not have non-skid strips on the floor as ordered by the physician. Additionally, the resident's walker was not within reach, contrary to the care plan's interventions. These oversights were confirmed by staff interviews, highlighting a failure to adhere to physician orders and care plan interventions designed to prevent falls. The facility's policy on falls emphasized the need to evaluate, document, and revise care plans to prevent further incidents, which was not adequately followed in these cases.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed as ordered for a resident, which was identified during a survey. The medical record review for a resident revealed an admission with diagnoses including kidney failure, congestive heart failure, and a history of stroke. The resident was moderately cognitively impaired and required assistance with daily activities. The care plan indicated the resident had ineffective breathing patterns and required oxygen administration per physician's orders. However, the physician's order to change the oxygen tubing weekly was not followed, as the tubing in use was dated three weeks prior to the observation. A registered nurse confirmed the tubing should have been changed weekly, as per the facility's policy on oxygen administration.
Failure to Enforce Abuse Policy and Investigate Allegation
Penalty
Summary
The facility failed to enforce its abuse policy by not promptly reporting an allegation of abuse, not immediately investigating the allegation of staff-to-resident abuse, and not ensuring the alleged perpetrator was removed from providing direct care to residents. This incident involved a resident who reported improper incontinence care by a CNA. The resident, who had diagnoses including COPD, diabetes, and spinal stenosis, expressed discomfort with the way the CNA provided care, but did not initially describe the incident as abusive. The facility's investigation was delayed, and the CNA continued to work with residents after the allegation was made. Witness statements and interviews revealed inconsistencies in the accounts of the incident, with some staff members unaware of any allegations and others reporting that the resident felt uncomfortable with the care provided. The facility did not report the incident to the Ohio Department of Health or local law enforcement immediately, as required by their policy. The facility's abuse policy mandates immediate reporting of all allegations to the administrator and the Ohio Department of Health, as well as the removal of the accused staff member from the facility pending investigation. However, the facility did not adhere to these procedures, resulting in a deficiency. The investigation was not completed within the required timeframe, and key witness statements were not obtained, contributing to the non-compliance finding.
Failure to Investigate and Protect Resident from Alleged Abuse
Penalty
Summary
The facility failed to immediately investigate and implement protective measures upon receiving an allegation of staff-to-resident abuse. This involved a resident who had reported improper incontinence care by a male Certified Nursing Assistant (CNA). The resident, who had intact cognition and was dependent on staff assistance, expressed discomfort with the way the CNA provided care, describing it as degrading. Despite the resident's report, the facility did not document the allegation in the nursing notes, and the CNA continued to work in the facility for several weeks before being suspended. The facility's investigation into the incident was delayed, and the alleged perpetrator was not removed from providing direct care immediately, as required by the facility's abuse policy. The Director of Nursing (DON) and the Administrator were informed of the incident, but the investigation was not initiated until several weeks later, after the allegation was reported to corporate. During this time, the CNA continued to work on both the men's and women's units, potentially affecting all residents in the facility. Interviews with staff and the resident revealed inconsistencies in the reporting and handling of the incident. The resident's daughter and other staff members corroborated the resident's account of feeling uncomfortable with the care provided. However, the facility's administration did not perceive the incident as abuse initially, and the investigation was not thorough. The facility's policy required immediate removal of the accused staff member and a comprehensive investigation, which was not adhered to, leading to a deficiency in handling the abuse allegation.
QAPI Committee Lacks Required Members
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee met at least quarterly with the required members, including the medical director or their designee. The review of QAPI sign-in sheets from October 2023 to August 2024 revealed that while a meeting was held in March 2024 with the medical director present, a subsequent meeting in June 2024 did not have the medical director or a designee in attendance. Another meeting in August 2024 was attended by a nurse practitioner as the medical director's designee. There was no documented evidence of a QAPI meeting with the medical director or designee from March to August 2024, a period exceeding five months. An interview with the Administrator confirmed the absence of such documentation. Additionally, the facility's policy on Quality Assurance Performance Improvement, dated July 2024, did not specify the required members for these meetings, including the medical director or designee. This deficiency was identified during a complaint investigation.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician or designee regarding a change in condition for Resident #13, who was admitted with diagnoses including chronic obstructive pulmonary disease, hypertension, congestive heart failure, and oxygen dependence. The resident's blood pressure readings from 10/24/24 to 11/07/24 showed a significant drop on 11/07/24 to 72/55, which was later rechecked and found to be 96/56 with a heart rate of 56. Despite this low blood pressure, LPN #604 administered the resident's morning medications, which included several that could further affect blood pressure and heart rate, without consulting the physician or nurse practitioner. The nurse practitioner, who was familiar with the resident, indicated that the low blood pressure warranted physician notification and potential adjustments to the medication regimen, such as holding certain medications and conducting further assessments. The Director of Nursing confirmed that the LPN should have contacted the physician before administering the medications. The facility's policy on notifying physicians of changes in a resident's condition lacked specific guidelines on when to notify, contributing to the oversight. This deficiency was identified during an investigation under Master Complaint Number OH00159487.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to promptly report an allegation of staff-to-resident sexual abuse involving a resident with chronic obstructive pulmonary disease, diabetes, and spinal stenosis. The incident occurred when a CNA was providing incontinence care, and the resident expressed discomfort with the manner in which the care was provided. Despite the resident's report of discomfort and the involvement of multiple staff members, the facility did not report the incident to the Ohio Department of Health, local police, or the resident's physician until several weeks later. The incident was initially reported by a CNA who witnessed the resident's discomfort and reported it to the Director of Nursing (DON) and the Administrator. However, the facility did not take immediate action to report the incident as required by their abuse policy. The resident later described the incident as uncomfortable but did not label it as sexual abuse. Despite this, the facility's policy required all allegations of abuse to be reported immediately, which was not done in this case. Interviews with staff revealed discrepancies in the handling of the incident, with some staff members feeling that the incident was not thoroughly investigated due to the CNA involved being related to the Administrator. The facility's failure to report the incident promptly and conduct a thorough investigation led to a deficiency being cited under Complaint Number OH00159263.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which was identified during a survey. Resident #36, who had diagnoses including chronic obstructive pulmonary disease, diabetes, and paranoid schizophrenia, was observed lying in bed without a call light within reach. Her care plan indicated she was at risk for falls due to impaired mobility and required the call light to be accessible. Despite having intact cognition and being dependent on staff for most care activities, her call light was found on the other bed in her room, approximately ten feet away, making it inaccessible. Similarly, Resident #33, with diagnoses of arthritis and hypertension, was also found without her call light within reach. Her care plan noted she was at risk for falls and required assistance with daily activities. During observation, her call light was placed on her nightstand, out of her reach. Interviews with the residents and staff confirmed these findings. The facility's policy required call lights to be within reach, but this was not adhered to, leading to the deficiency being noted.
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen according to physician orders and did not provide appropriate signage indicating oxygen use for a resident. Resident #13, who had diagnoses including chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), was observed receiving 4.5 liters per minute of oxygen via nasal cannula, contrary to the physician's order of three liters per minute. Additionally, there was no signage outside the resident's room indicating oxygen was in use, which is a requirement according to the facility's policy. Further observations revealed that an LPN removed an oxygen e-cylinder from the resident's room and stored it in a central supply room without appropriate signage indicating the presence of oxygen. The Director of Nursing confirmed the discrepancy in the oxygen administration and the lack of signage, acknowledging that the central supply room was being used for oxygen storage without her knowledge. The facility's policy mandates checking physician orders for oxygen administration and placing signs where oxygen is in use, which was not adhered to in this instance.
Infection Control and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to implement proper infection control measures, particularly in the use of Enhanced Barrier Precautions (EBP) for Resident #13, who had a coccyx pressure wound. Despite a care plan indicating the need for EBP, a Licensed Practical Nurse (LPN) did not wear a gown during high-contact care activities, such as repositioning and transferring the resident. The LPN also carried medications against her chest, potentially causing cross-contamination, and admitted to not being informed of any contagious disease in Resident #13, despite the presence of a sign indicating EBP was required. Additionally, the facility did not ensure proper cleaning of medical equipment between resident uses. An LPN used an electric blood pressure monitor on two residents without cleaning the cuff and monitor between uses, which was confirmed by the LPN and the Director of Nursing (DON). The facility's policy did not specifically address the cleaning of blood pressure cuffs and monitors between residents, contributing to this oversight. The facility also failed to store a bedpan in a sanitary manner for Resident #35, who was dependent on staff for toileting hygiene. The bedpan was observed lying uncovered on the bathroom floor, which was verified by a Certified Nursing Assistant (CNA) and the DON. The facility lacked a policy on bedpan storage, and the DON acknowledged that bedpans should be stored in a bag, not directly on the floor.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willows Health And Rehab Ctr | 0.4 mi | ★★★★★ | 0 | 0 |
| Eastbrook Healthcare Center | 0.5 mi | ★★★★★ | 18 | 0 |
| Mount Saint Joseph Rehab Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Slovene Home For The Aged | 1.7 mi | ★★★★★ | 1 | 0 |
| Gardens Of Mcgregor And Amasa Stone | 1.9 mi | ★★★★★ | 20 | 0 |
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