Inspection Reports for
Hillside Manor Rehab & Extended Care Center
182-15 Hillside Avenue, Jamaica Estates, NY, 11432
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 16, 2025
Visit Reason
One isolated Level 2 deficiency related to cardio-pulmonary resuscitation (CPR) with no actual harm but potential for minor harm.
Findings
One isolated Level 2 deficiency related to cardio-pulmonary resuscitation (CPR) with no actual harm but potential for minor harm.
Deficiencies (1)
Cardio-pulmonary resuscitation (cpr)
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 16, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with advance directives and cardiopulmonary resuscitation procedures following an incident involving a resident with a Do Not Resuscitate order.
Findings
The facility failed to ensure that a resident's Do Not Resuscitate order was followed, resulting in inappropriate cardiopulmonary resuscitation being performed. Immediate corrective actions were taken, including staff training, audits, and removal of involved staff members.
Deficiencies (1)
F 0678: The facility failed to follow a resident's Do Not Resuscitate order and performed cardiopulmonary resuscitation despite the resident having a signed Medical Order for Life Sustaining Treatment indicating Do Not Resuscitate.
Report Facts
Residents sampled: 10
Registered Nurses in-serviced: 53
Licensed Practical Nurses in-serviced: 29
Certified Nursing Assistants in-serviced: 171
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | First responder who failed to check resident's wristband and electronic record for Do Not Resuscitate order |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Assessed resident, continued CPR until EMS arrival, later discovered Do Not Resuscitate order |
| Physician Assistant #1 | Physician Assistant | Provided telephone orders during incident |
| Director of Nursing | Director of Nursing | Provided facility protocol and confirmed staff errors |
| Administrator | Administrator | Notified of incident and staff failures |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Performed rescue breathing during incident |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Mar 31, 2025
Visit Reason
Multiple Level 2 deficiencies in standard health citations including care plan development, medication error rates, reporting alleged violations, and services meeting professional standards; several life safety code deficiencies corrected by May 2025.
Findings
Multiple Level 2 deficiencies in standard health citations including care plan development, medication error rates, reporting alleged violations, and services meeting professional standards; several life safety code deficiencies corrected by May 2025.
Deficiencies (10)
Develop/implement comprehensive care plan
Free of medication error rts 5 prcnt or more
Reporting of alleged violations
Services provided meet professional standards
Electrical equipment - power cords and extens
Electrical systems - other
Gas equipment - cylinder and container storag
Physical environment
Sprinkler system - installation
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 31, 2025
Visit Reason
The inspection was conducted as a Recertification and Abbreviated Survey to assess compliance with federal and state regulations, including investigation of alleged abuse incidents.
Findings
The facility failed to timely report an alleged abuse incident involving Resident #230, who sustained a right pelvic fracture from an unwitnessed fall on 05/17/2024. The incident was not reported to the New York State Department of Health within the required 2-hour timeframe.
Deficiencies (1)
F 0609: The facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were reported immediately, but not later than 2 hours after the allegation. Resident #230's injury from an unwitnessed fall was not reported to the state as required.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Nursing Supervisor | Assessed Resident #230 and provided statements regarding the incident |
| Licensed Practical Nurse 2 | Completed Nurse's Investigation Statement form regarding Resident #230 | |
| Certified Nurse Aide 3 | Found Resident #230 sitting on the gym mat and called for help | |
| Director of Nursing | Provided statements about the incident reporting and investigation |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 31, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 03/24/2025 to 03/31/2025 to assess compliance with federal and state regulations for nursing home care.
Findings
The facility failed to develop and implement comprehensive person-centered care plans for residents, and did not ensure services met professional standards of quality. Medication administration errors were observed, resulting in a medication error rate of 7.14%, exceeding the acceptable threshold.
Deficiencies (3)
F 0656: The facility did not develop and implement comprehensive care plans with measurable objectives and time frames for residents, including pain management and diabetes care.
F 0658: The facility did not ensure services met professional standards of quality, evidenced by medication administration errors including administering the wrong medication to a resident.
F 0759: The facility did not ensure medication error rates were below 5 percent, with errors including early signing for medication administration and administering medication prescribed for another resident.
Report Facts
Residents reviewed: 35
Residents observed during medication administration: 3
Medications given during medication administration task: 28
Medication errors: 2
Medication error rate: 7.14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Named in medication administration errors and interviews regarding medication errors | |
| Registered Nurse #4 | Interviewed regarding responsibility for care plans | |
| Registered Nurse #5 | Nursing Supervisor | Interviewed regarding care plans and medication administration practices |
| Medical Director | Interviewed regarding medication administration timing and practices | |
| Director of Nursing | Interviewed regarding medication administration competency training |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Sep 30, 2024
Visit Reason
The survey was conducted as an Abbreviated and Partial Extended Survey to investigate allegations of physical abuse of a resident by a Certified Nursing Assistant.
Complaint Details
The visit was complaint-related, triggered by allegations of physical abuse of Resident #1 by Certified Nursing Assistant #1 on 09/16/2024. The abuse was substantiated based on observations, interviews, and documentation including bruising and resident statements.
Findings
The facility failed to protect Resident #1 from physical abuse by Certified Nursing Assistant #1, who was observed forcefully handling and hitting the resident. Licensed Practical Nurse #1 witnessed the abuse but did not intervene or remove the abuser from resident care. Immediate Jeopardy was identified and later lifted after corrective actions including removal and termination of the abuser, staff counseling, and policy revisions.
Deficiencies (3)
F 0600: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. The facility failed to protect Resident #1 from physical abuse by Certified Nursing Assistant #1, who was observed forcefully handling and hitting the resident multiple times. Licensed Practical Nurse #1 witnessed the abuse but did not intervene or remove the abuser from resident care.
F 0610: Respond appropriately to all alleged violations. The facility failed to remove Certified Nursing Assistant #1 from resident care after witnessed abuse, allowing further harm to Resident #1. Licensed Practical Nurse #1 observed the abuse but did not intervene or remove the abuser.
F 0835: Administer the facility in a manner that enables it to use its resources effectively and efficiently. The facility's administration failed to ensure effective operation to prevent abuse, including inadequate in-service training on how staff should respond when resident abuse is witnessed or suspected.
Report Facts
Residents assessed for bruising: 12
Staff in-service completion rate: 98
Severity score: 10
Pain score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Witnessed abuse of Resident #1 but did not intervene or remove abuser; reported incident after delay. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Perpetrator of physical abuse against Resident #1; removed from duty and terminated. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Witnessed abuse and was counseled and suspended for abuse prevention and reporting failures. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Received abuse report from Licensed Practical Nurse #1 and assisted in care of Resident #1. |
| Director of Nursing | Director of Nursing | Notified of abuse incident; directed police notification and removal of abuser; acknowledged failures in intervention. |
| Administrator | Facility Administrator | Notified of abuse incident; involved in investigation and corrective actions. |
| Attending Physician #1 | Attending Physician | Evaluated Resident #1 post-abuse and ordered immediate x-ray. |
| Medical Director | Medical Director | Reviewed Resident #1's chart and concluded minor injury managed successfully without hospital transfer. |
| Psychiatrist | Psychiatrist | Evaluated Resident #1 and documented no psychosocial harm. |
| Psychologist | Psychologist | Evaluated Resident #1 and recommended individual psychotherapy to reduce emotional symptoms. |
| In-service Coordinator #1 | In-service Coordinator | Acknowledged lesson plan deficiencies and planned additional in-service on abuse prevention. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Sep 30, 2024
Visit Reason
Two isolated Level 4 immediate jeopardy deficiencies related to abuse prevention and investigation, plus other Level 2 deficiencies in administration and resident rights; all corrected by November 2024.
Findings
Two isolated Level 4 immediate jeopardy deficiencies related to abuse prevention and investigation, plus other Level 2 deficiencies in administration and resident rights; all corrected by November 2024.
Deficiencies (3)
Administration
Free from abuse and neglect
Investigate/prevent/correct alleged violation
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 8
Date: Dec 13, 2023
Visit Reason
Multiple isolated Level 2 deficiencies in standard health citations including assessments, food safety, resident rights, and life safety code issues; all corrected by early 2024.
Findings
Multiple isolated Level 2 deficiencies in standard health citations including assessments, food safety, resident rights, and life safety code issues; all corrected by early 2024.
Deficiencies (8)
Accuracy of assessments
Encoding/transmitting resident assessments
Food procurement,store/prepare/serve-sanitary
Label/store drugs and biologicals
Resident rights/exercise of rights
Cooking facilities
Electrical equipment - testing and maintenanc
Smoke detection
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 5
Date: Dec 13, 2023
Visit Reason
The inspection was conducted as a recertification survey from 12/6/2023 to 12/13/2023 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, timely and accurate Minimum Data Set (MDS) assessments, secure storage of controlled medications, and proper food storage in pantry refrigerators. All deficiencies were cited with minimal harm and affected few residents or units.
Deficiencies (5)
F 0550: The facility did not ensure residents were treated with respect and dignity during feeding; staff were observed standing over a resident instead of sitting down as required by policy.
F 0640: The facility failed to transmit Minimum Data Set (MDS) assessments electronically to CMS within 14 days of completion for one resident.
F 0641: The facility did not ensure MDS assessments accurately reflected resident status, including discharge and refusal of care, for two residents.
F 0761: The facility did not ensure controlled medications were stored in separately locked compartments; a lock on the controlled medication cabinet was broken for one unit.
F 0812: The facility did not store food according to professional standards; a pantry refrigerator on the 5th floor was observed at 56°F containing unlabeled and undated food.
Report Facts
Residents sampled: 38
Residents reviewed for MDS assessment: 17
Residents affected by dignity deficiency: 1
Residents affected by MDS transmission deficiency: 1
Residents affected by MDS accuracy deficiency: 2
Units observed for medication storage: 5
Units affected by medication storage deficiency: 1
Floor pantries observed: 10
Floor pantries affected by food storage deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed standing over resident during feeding and reported broken lock on medication cabinet |
| CNA #1 | Certified Nursing Assistant | Observed standing over resident during feeding |
| RNS #1 | Registered Nurse Supervisor | Interviewed regarding feeding practices and pantry refrigerator maintenance |
| MDS Coordinator | Responsible for submitting MDS assessments and interviewed about late submissions and accuracy | |
| MDS Assessor #1 | Interviewed about accuracy of MDS assessments | |
| Director of Nursing | Director of Nursing | Interviewed about medication cabinet lock repair and pantry refrigerator replacement |
| Administrator | Administrator | Interviewed regarding MDS submission oversight |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 10, 2023
Visit Reason
One Level 0 deficiency related to requirements before submitting a request; corrected by December 2023.
Findings
One Level 0 deficiency related to requirements before submitting a request; corrected by December 2023.
Deficiencies (1)
Requirements before submitting a request for
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Oct 19, 2021
Visit Reason
Multiple isolated Level 2 deficiencies in assessments, care planning, food safety, infection control, reporting violations, and environment; all corrected by December 2021.
Findings
Multiple isolated Level 2 deficiencies in assessments, care planning, food safety, infection control, reporting violations, and environment; all corrected by December 2021.
Deficiencies (9)
Accuracy of assessments
Activities meet interest/needs each resident
Care plan timing and revision
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Reporting of alleged violations
Safe/clean/comfortable/homelike environment
Subsistence needs for staff and patients
Hazardous areas - enclosure
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 19, 2021
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements for nursing home operations, including environment, resident assessments, care planning, activities, food service, and infection control.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, ensuring accurate resident assessments, involving residents in care planning, providing adequate activities, maintaining food service safety standards, and implementing infection prevention and control practices.
Deficiencies (6)
F 0584: The facility failed to maintain a sanitary, orderly, and comfortable environment, evidenced by torn privacy curtains, peeling wallpaper, and soiled feeding tube poles on Units 2 and 3.
F 0641: The facility did not ensure accurate resident assessments; specifically, a resident's MDS incorrectly documented insulin injections that were not administered.
F 0657: The facility failed to invite residents or their representatives to quarterly care plan meetings, limiting resident participation in care planning.
F 0679: The facility did not provide an ongoing activities program meeting residents' interests and needs, with observations of residents not engaged in activities and lack of activity materials in rooms.
F 0812: Staff in the kitchen were observed not wearing hairnets properly, risking foodborne illness due to improper food service safety practices.
F 0880: The facility failed to maintain infection prevention practices; a resident's urinary catheter bag was touching the floor and oxygen tubing was observed on the floor, risking infection transmission.
Report Facts
Residents reviewed: 38
Units observed: 8
Care plan meetings missed: 3
Live music attendance: 4
Personal visits: 14
Sensory visits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding environmental rounds and curtain replacement |
| DOH | Director of Housekeeping | Interviewed about housekeeping rounds and curtain maintenance |
| RN #7 | Registered Nurse | Interviewed about medication administration and resident assessment accuracy |
| MDSA | MDS Assessor | Interviewed about MDS assessment data collection and coding error |
| MDSC | MDS Coordinator | Interviewed about MDS assessment review process |
| SW #1 | Social Worker | Interviewed about care plan meeting invitations |
| DSS | Director of Social Services | Interviewed about care plan meeting policies |
| RNS #2 | Registered Nurse Supervisor | Interviewed about care plan meetings and quarterly assessments |
| CNA #11 | Certified Nursing Assistant | Interviewed about resident activity participation |
| RL #1 | Recreation Leader | Interviewed about activities provided to residents |
| DA | Director of Activities | Interviewed about recreation programming and resident engagement |
| DA #1 | Dietary Aide | Interviewed about hairnet use and food service safety |
| FSS | Food Service Supervisor | Interviewed about dietary staff supervision and hairnet policy |
| FSD | Food Service Director | Interviewed about staff orientation and hairnet policy enforcement |
| CNA #5 | Certified Nursing Assistant | Interviewed about urinary catheter care |
| RNS #2 | Registered Nurse Supervisor | Interviewed about catheter care rounds and infection control |
| CNA #4 | Certified Nursing Assistant | Interviewed about oxygen tubing care |
| RN #1 | Registered Nurse | Interviewed about oxygen tubing rounds and patient safety |
| DON | Director of Nursing | Interviewed about oxygen tubing monitoring and infection prevention |
| IP | Infection Preventionist | Interviewed about infection control rounds and urinary catheter care |
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