Inspection Reports for Complete Care at Hillside LLC

810 South Broom Street, Wilmington, DE, 19805

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Inspection Report Summary

The most recent inspection on February 6, 2025, identified multiple deficiencies across several areas including medication self-administration, call light accessibility, abuse investigation, care planning, staffing, pressure ulcer prevention, respiratory care, psychotropic drug use, infection control, immunizations, and resident call system functionality. Earlier inspections also noted deficiencies related to care planning, infection control, respiratory care, staffing, food safety, and abuse reporting, with substantiated complaints regarding abuse investigations and infection control. The main themes of deficiencies have consistently involved resident care planning, infection prevention, medication management, and staff qualifications. Complaint investigations were substantiated in several surveys, particularly concerning abuse investigations and infection control practices. The inspection history shows ongoing challenges with compliance in multiple care and safety areas, with no clear improvement trend over time.

Deficiencies (last 5 years)

Deficiencies (over 5 years) 13 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

48% worse than Delaware average
Delaware average: 8.8 deficiencies/year

Deficiencies per year

16 12 8 4 0
2020
2022
2023
2024
2025

Census

Latest occupancy rate 96 residents

Based on a February 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

72 80 88 96 104 Dec 2020 Jan 2022 Nov 2023 Feb 2024 Feb 2025

Inspection Report

Routine
Deficiencies: 15 Date: Feb 6, 2025

Visit Reason
The inspection was a routine survey of Complete Care at Hillside LLC to assess compliance with healthcare regulations and standards.

Findings
The facility was found deficient in multiple areas including medication management, resident care plans, infection control, respiratory care, call light functionality, bed rail use, and vaccination consent. Several residents were found to have unmet care needs or safety risks, such as improper medication storage, incomplete care plans, inadequate infection precautions, and malfunctioning call systems.

Deficiencies (15)
Failed to ensure medications were not left at bedside for residents not assessed to self-administer medications.
Failed to ensure call lights were within reach for residents.
Failed to investigate misappropriation of property for residents.
Failed to develop comprehensive care plans related to nebulizer treatment for a resident.
Failed to ensure residents unable to perform ADLs received necessary personal hygiene services.
Failed to ensure the activities program was directed by a qualified professional.
Failed to provide treatment and interventions for pressure ulcers according to physician orders.
Failed to ensure proper catheter care and positioning to prevent urinary tract infections.
Failed to provide necessary respiratory care and services in accordance with professional standards.
Failed to ensure residents received alternative measures prior to installation of side rails and proper assessment and consent for bed rail use.
Failed to ensure medical necessity and informed consent for psychotropic medication administration.
Failed to ensure resident medication stored in medication carts was appropriately labeled with open/discard dates.
Failed to ensure facility infection control procedures were followed related to Transmission Based Precautions/Isolation for residents with respiratory symptoms.
Failed to ensure risks versus benefits were provided and documented prior to pneumococcal vaccination.
Failed to ensure a working call system was available in a resident's bathroom and bathing area.
Report Facts
Residents reviewed: 47 Residents affected: 2 Residents affected: 1 Residents affected: 2 Residents affected: 1 Residents affected: 4 Residents affected: 1 Residents affected: 3

Employees mentioned
NameTitleContext
LPN7Licensed Practical NurseObserved administering insulin incorrectly and interviewed about insulin pen use
LPN8Licensed Practical NurseInterviewed about insulin pens lacking open/discard dates
LPN9Licensed Practical NurseInterviewed about insulin pens lacking open/discard dates
Director of NursingDirector of NursingInterviewed regarding multiple deficiencies including medication consent and infection control
AdministratorAdministratorInterviewed regarding multiple deficiencies including medication consent, infection control, and call light issues
Infection PreventionistInfection Preventionist/Educator Nurse PracticeInterviewed regarding infection control and insulin pen labeling
LPN4Licensed Practical NurseInterviewed regarding wound care and medication orders
LPN5Licensed Practical NurseInterviewed regarding wound care and catheter bag positioning
LPN6Licensed Practical NurseInterviewed regarding catheter bag positioning and bed rail consent
Activity DirectorActivity DirectorInterviewed regarding qualifications and certification status

Inspection Report

Complaint Investigation
Census: 96 Deficiencies: 13 Date: Feb 6, 2025

Visit Reason
A Recertification, Complaint, and Emergency Preparedness survey was conducted from 02/03/25 to 02/06/25 by Healthcare Management Solutions LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality.

Complaint Details
The survey included a complaint investigation related to allegations of abuse, neglect, and misappropriation of property. The facility failed to investigate thoroughly and timely. The complaint was substantiated as evidenced by findings related to failure to investigate and prevent further abuse and misappropriation.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in areas including medication self-administration, reasonable accommodations for call lights, investigation of alleged abuse and misappropriation of property, comprehensive care planning, ADL care, qualified activity professional staffing, pressure ulcer prevention, respiratory care, psychotropic drug use, insulin pen procedures, infection control, pneumococcal and influenza immunizations, and resident call system functionality.

Deficiencies (13)
Failed to ensure medications were not left at bedside for residents not assessed to self-administer medications.
Failed to ensure call lights were within reach for residents.
Failed to investigate allegations of abuse and misappropriation of property thoroughly and timely.
Failed to develop comprehensive care plans related to nebulizer treatments.
Failed to ensure residents received necessary ADL care including bathing and showering.
Failed to hire a qualified activity professional.
Failed to provide adequate pressure ulcer prevention and treatment.
Failed to provide necessary respiratory care and education for residents with nebulizer treatments.
Failed to ensure informed consent and proper administration of psychotropic medications.
Failed to ensure insulin pens were properly labeled and disposed of.
Failed to maintain an effective infection prevention and control program.
Failed to ensure residents received pneumococcal and influenza immunizations or education.
Failed to maintain a functional resident call system.
Report Facts
Survey Census: 96 Sample Size: 47 Supplemental Residents: 9 Deficiencies cited: 13

Employees mentioned
NameTitleContext
R24Resident involved in medication self-administration deficiency.
R298Resident involved in medication self-administration deficiency.
Director of NursingDONObserved medication deficiencies and conducted audits.
Licensed Practical Nurse 4LPN 4Observed call light placement deficiency.
Licensed Practical Nurse 5LPN 5Involved in wound care and insulin pen labeling deficiencies.
Certified Nurse Aide 1CNA1Involved in abuse investigation.
AdministratorProvided statements and education related to deficiencies.
Assistant Director of NursingADONConducted audits and education related to nebulizer treatments.
Licensed Practical Nurse 3LPN 3Observed nebulizer medication administration.
Licensed Practical Nurse 6LPN 6Observed catheter bag placement.
Licensed Practical Nurse 7LPN 7Observed respiratory symptoms and insulin pen administration.
Licensed Practical Nurse 8LPN 8Failed to label insulin pens properly.
Licensed Practical Nurse 9LPN 9Observed insulin pen administration.
Infection Preventionist/Educator Nurse PracticeIP/ENPProvided infection control education and observations.
Resource NurseAddressed shower/bath documentation issues.

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Feb 1, 2024

Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to accurately assess a resident after an unwitnessed fall and failure to implement additional interventions to prevent future falls, as well as concerns about infection prevention and control practices.

Complaint Details
The complaint investigation focused on the fall of Resident 10 and infection control practices. The fall risk assessment was found inaccurate, and the Director of Nursing confirmed no additional interventions were added after the fall. Infection control observations revealed multiple failures in PPE use and hand hygiene. The Director of Nursing acknowledged the need for improved compliance.
Findings
The facility failed to accurately assess one resident (R10) after an unwitnessed fall and did not implement additional fall prevention interventions. Additionally, the facility failed to maintain proper infection prevention and control practices, including donning and doffing PPE, hand hygiene, and isolation precautions, potentially affecting all residents.

Deficiencies (2)
Failed to accurately assess one resident after an unwitnessed fall and failed to put additional interventions in place to prevent future falls for Resident 10.
Failed to establish and maintain an infection prevention and control program, including improper donning and doffing procedures, hand hygiene, and isolation precautions.
Report Facts
Residents affected: 3 Residents affected: 98

Employees mentioned
NameTitleContext
LPN 14Licensed Practical NurseConducted fall risk assessment and was interviewed about Resident 10's fall
LPN 11Licensed Practical NurseInterviewed regarding PPE doffing and infection control practices
RN 15Registered NurseSigned nursing progress note related to Resident 10's fall
Director of NursingDirector of NursingInterviewed about fall and infection control practices
CNA 20Certified Nurse AideObserved donning and doffing PPE in COVID-19 isolation room
CNA 2Certified Nursing AssistantObserved emptying urinals without gloves on Resident 64
Infection PreventionistInfection PreventionistInterviewed about infection control education and PPE compliance

Inspection Report

Routine
Deficiencies: 6 Date: Feb 1, 2024

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations.

Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, incomplete care planning for PTSD, inaccurate fall risk assessment and prevention, lack of physician order for oxygen therapy, improper food storage and labeling, and inadequate infection prevention and control practices.

Deficiencies (6)
Failure to ensure call lights were within reach for three residents, impacting their ability to maintain independence and dignity.
Failure to develop and implement a comprehensive care plan addressing PTSD for one resident.
Failure to accurately assess and implement interventions after an unwitnessed fall for one resident.
Failure to obtain a physician's order for oxygen therapy for one resident.
Failure to ensure resident food stored in nourishment room refrigerators was stored in a sanitary manner with proper labeling and dating.
Failure to establish and maintain an infection prevention and control program including proper donning and doffing of PPE, hand hygiene, and isolation precautions.
Report Facts
Residents reviewed for accommodation of needs: 40 Residents affected: 3 Residents reviewed for care plans: 40 Residents affected: 1 Residents reviewed for falls: 3 Residents affected: 1 Residents reviewed for oxygen therapy: 4 Residents affected: 1 Residents affected: 96 Total residents: 98 Residents affected: 98

Employees mentioned
NameTitleContext
Licensed Practical Nurse 13LPNObserved call light accessibility issues and confirmed deficiencies
Assistant Director of NursingADONInterviewed regarding care plan responsibilities and knowledge of PTSD care plan
Director of NursingDONInterviewed regarding care plan oversight, fall risk assessment, oxygen orders, and infection control
Licensed Practical Nurse 14LPNInterviewed regarding fall incident and assessment
Certified Nursing Assistant 6CNAInterviewed regarding call light accessibility and infection control observations
Certified Nursing Assistant 9CNAInterviewed regarding call light accessibility and infection control observations
Certified Nursing Assistant 20CNAObserved donning and doffing PPE in COVID-19 isolation room
Licensed Practical Nurse 11LPNInterviewed regarding oxygen therapy orders and infection control practices
Certified Nursing Assistant 2CNAObserved and interviewed regarding improper glove use during urinal emptying
Infection PreventionistIPInterviewed regarding infection control education, PPE compliance, and isolation practices
Corporate Dietary Manager 27CDMAssisted with refrigerator inspections and verified food storage deficiencies

Inspection Report

Complaint Investigation
Census: 98 Deficiencies: 6 Date: Feb 1, 2024

Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC, on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality from 01/29/24 through 02/01/24.

Complaint Details
The survey included complaint investigation components as indicated by the presence of complaint-related deficiencies and substantiation of issues such as call bell accessibility and infection control.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to reasonable accommodations for resident needs, comprehensive care plans, fall prevention, respiratory care, food safety, and infection control.

Deficiencies (6)
Facility failed to ensure call bells were within reach for three residents.
Facility failed to develop and implement a person-centered comprehensive care plan for one of 40 sampled residents.
Facility failed to accurately assess one resident after an unwitnessed fall and failed to put additional interventions in place to prevent future falls.
Facility failed to obtain a physician's order for the use of oxygen for one of four residents reviewed for oxygen therapy.
Facility failed to ensure resident food stored in refrigerators was stored in a sanitary manner.
Facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Report Facts
Survey Census: 98 Sample Size: 40 Supplemental Residents: 4 Deficiencies cited: 6 Physician order liters per minute: 3

Employees mentioned
NameTitleContext
Licensed Practical Nurse 13Licensed Practical NurseObserved call light button accessibility issues for resident R45
Licensed Practical Nurse 14Licensed Practical NurseInterviewed regarding resident R10 fall and oxygen use
Director of NursingDirector of NursingInterviewed regarding call light accessibility and fall prevention
Assistant Director of NursingAssistant Director of NursingInterviewed regarding care plans for residents
Certified Nursing Assistant 2Certified Nursing AssistantInterviewed regarding care plan knowledge for resident R87
Certified Nursing Assistant 6Certified Nursing AssistantInterviewed regarding oxygen management
Certified Nursing Assistant 9Certified Nursing AssistantInterviewed regarding oxygen management
Infection PreventionistInfection PreventionistInterviewed regarding infection control practices

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: Nov 17, 2023

Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to implement a care plan for a resident's continuous use of oxygen and failure to provide appropriate treatment and nursing care according to physician orders and professional standards.

Complaint Details
The complaint investigation focused on the care of resident R1, who had a significant change in condition on 11/14/23, became unresponsive, and was transported to the hospital without proper nursing assessment including vital signs. The investigation found failures in care plan implementation, treatment, nursing competency, and emergency response.
Findings
The facility failed to implement a care plan for resident R1's oxygen use and did not provide appropriate treatment and assessments during a significant change in R1's condition, including failure to perform vital sign assessments and respiratory interventions. The facility also lacked proper nursing competencies and training related to emergency equipment use and RN supervisory roles.

Deficiencies (4)
Failed to implement a care plan for R1's continuous use of oxygen.
Failed to ensure R1 received treatment and care in accordance with professional standards and physician orders, including lack of nursing assessment and vital signs during a change in condition.
Lack of assessments for blood pressure, pulse, blood sugar, temperature and lung sounds after R1 was found unresponsive.
Failed to provide competent nursing care including assessments and interventions for a resident who experienced a change in respiratory condition.
Report Facts
Physician's oxygen order: 2 Date of resident admission: Oct 12, 2023 Date of significant change in condition: Nov 14, 2023 Date of survey completion: Nov 17, 2023

Employees mentioned
NameTitleContext
E3RN SupervisorNamed in failure to assess resident R1 during change in condition and calling 911
E1NHA (Nursing Home Administrator)Reviewed findings with surveyors
E2DON (Director of Nursing)Reviewed findings with surveyors
E5Staff EducatorInterviewed regarding nursing orientation and emergency cart training
E4Regional Clinical ConsultantReviewed findings with surveyors

Inspection Report

Annual Inspection
Census: 94 Deficiencies: 3 Date: Nov 17, 2023

Visit Reason
An unannounced annual survey was conducted from November 16 to November 17, 2023, to assess compliance with regulatory requirements for skilled and intermediate care facilities.

Complaint Details
The survey was an unannounced Complaint Survey conducted from November 16 to November 17, 2023. The deficiencies were based on interviews, clinical record reviews, and facility documentation. The facility census was 94 on the first day of the survey. The complaint was substantiated as deficiencies were found.
Findings
The survey identified deficiencies related to care plan timing and revision, quality of care, and competent nursing staff, particularly concerning the care and oxygen use for one resident (R1). The facility failed to implement a care plan for continuous oxygen use and did not ensure proper assessments and emergency management training for staff.

Deficiencies (3)
Care Plan Timing and Revision - Facility failed to implement a care plan for R1's continuous use of oxygen.
Quality of Care - Facility failed to ensure treatment and care in accordance with professional standards; R1 had a change in condition and was unresponsive without proper assessments.
Competent Nursing Staff - Facility failed to provide competent nursing care including assessments and interventions for a resident with a change in respiratory condition; staff lacked hands-on review/use of emergency cart.
Report Facts
Facility census: 94 Survey sample size: 3 Completion date for plan of correction: 12/20/2023

Employees mentioned
NameTitleContext
E1Nursing Home Administrator (NHA)Reviewed findings with surveyors
E2Director of Nursing (DON)Reviewed findings with surveyors
E3RN SupervisorInvolved in resident care and interviews related to deficiencies
E4Regional Clinical ConsultantReviewed findings with surveyors
E5Staff Educator (RN)Interviewed regarding nursing orientation and emergency cart training

Inspection Report

Annual Inspection
Deficiencies: 6 Date: Jan 19, 2022

Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements related to resident care, medication administration, dietary services, and facility sanitation.

Findings
The facility was found deficient in multiple areas including failure to notify the Ombudsman of hospital transfers, incomplete care plans for residents, medication administration errors, failure to review lab results timely, failure to follow prescribed therapeutic diets, and unsanitary food storage and preparation conditions.

Deficiencies (6)
Failure to notify the Ombudsman of hospital transfers for two residents.
Failure to develop comprehensive care plans for identified resident care areas including catheter care and oxygen use.
Failure to ensure one resident received medication as ordered, resulting in a missed dose of antibiotic.
Failure to ensure lab results for Coumadin therapy were received and reviewed by the physician.
Failure to follow physician prescribed therapeutic diet for one resident during dining observation.
Failure to ensure food was stored, prepared, and served in a sanitary manner, including issues with paper towel dispenser, greasy fume hood, and inaccessible hand sink.
Report Facts
Residents sampled for hospitalization: 2 Residents in investigative sample: 19 Hospital transfer dates for R60: 5 Missed antibiotic doses: 1 INR lab result delay: 15 Date of inspection completion: Jan 19, 2022

Employees mentioned
NameTitleContext
E1NHAConfirmed failure to notify Ombudsman and reviewed findings during Exit Conference.
E2DONReviewed findings during Exit Conference.
E3ADONConfirmed no care plan for oxygen use.
E4RNUnable to locate INR lab result and contacted lab company.
E5FSDConfirmed dietary findings and food service deficiencies.
E6NPE/Staff DeveloperReviewed findings and interviewed regarding infection control and medication administration.
E7RDConfirmed dietary order was not followed during dining observation.
E8LPNUncertain if provider was notified about medication unavailability.
E9RNTranscribed and discontinued antibiotic orders for R60.
E10Regional Clinical ConsultantReviewed findings during Exit Conference.
E11Complete Care RepresentativeReviewed findings during Exit Conference.
E12Nurse PractitionerConfirmed expectation to be notified when medication was unavailable.

Inspection Report

Annual Inspection
Census: 88 Deficiencies: 9 Date: Jan 19, 2022

Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness survey was conducted at the facility from January 10, 2022 to January 19, 2022 to assess compliance with regulatory requirements.

Complaint Details
The complaint investigation found that the facility failed to immediately report an allegation of verbal abuse by a staff member on 12/20/20. The staff member was reeducated and disciplinary action was taken. Audits will be conducted weekly and monthly until compliance is achieved.
Findings
The facility was found to have multiple deficiencies based on observations, interviews, and clinical record reviews. Deficiencies included failure to meet minimum staffing requirements, failure to immediately report an allegation of abuse, failure to develop comprehensive care plans, failure to ensure timely medication administration, failure to monitor lab results, and failure to ensure food safety standards.

Deficiencies (9)
Facility failed to maintain minimum staffing requirement of 3.28 hours of direct care per resident per day.
Facility failed to immediately report an allegation of abuse for one resident.
Facility failed to notify the Office of the State Long-Term Care Ombudsman of hospital transfers for two residents.
Facility failed to develop comprehensive care plans for identified resident care areas.
Facility failed to ensure timely administration of new antibiotic medication for one resident.
Facility failed to monitor INR lab levels for one resident receiving Coumadin therapy.
Facility failed to ensure timely receipt and review of Coumadin lab results for one resident.
Facility failed to ensure physician's order for therapeutic diet was followed for one resident.
Facility failed to procure, store, prepare, and serve food in a sanitary manner; paper towel dispenser was improperly located.
Report Facts
Facility census: 88 Survey sample size: 45 Staffing hours: 3.28 Staffing hours: 2.84 Staffing hours: 3.09 Staffing hours: 3.26 Deficiency correction audit frequency: 4 Deficiency correction audit frequency: 3 Residents reviewed for abuse reporting: 5 Residents reviewed for care plans: 19 Residents reviewed for Coumadin therapy: 2 Residents reviewed for medication errors: 15

Employees mentioned
NameTitleContext
E14Certified Nurse's Aide (CNA)Reported observation of alleged verbal abuse
E15Certified Nurse's Aide (CNA)Confirmed report of alleged verbal abuse
E1Nursing Home Administrator (NHA)Reviewed findings and participated in exit conference
E2Director of Nursing (DON)Reviewed findings and participated in exit conference
E3Assistant Director of Nursing (ADON)Confirmed no care plan for oxygen use
E5Food Service Director (FSD)Confirmed dietary findings
E6Nurse Practice Educator (NPE)/Staff DeveloperReviewed findings and participated in exit conference
E7Registered Dietitian (RD)Confirmed dietary findings
E8Licensed Practical Nurse (LPN)Interviewed regarding medication availability
E10Regional Clinical ConsultantReviewed findings and participated in exit conference
E11Complete Care RepresentativeReviewed findings and participated in exit conference
E12Nurse PractitionerInterviewed regarding medication notification expectations
E13PhysicianAcknowledged lab monitoring deficiencies
E4Registered Nurse (RN)Interviewed regarding lab result receipt
E9Registered Nurse (RN)Received hospital order and transcribed medication order

Inspection Report

Complaint Investigation
Census: 79 Deficiencies: 1 Date: Dec 21, 2020

Visit Reason
A COVID-19 Focused Infection Control Survey and a complaint survey were conducted by the State of Delaware Division of Health Care Quality from December 17, 2020 through December 21, 2020 to assess compliance with infection control regulations and COVID-19 testing requirements.

Complaint Details
The complaint survey found the facility was not in compliance with COVID-19 testing requirements. The deficiency was substantiated by record review and interviews indicating employees E3 and E4 were not tested as required.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations, specifically failing to implement CMS and CDC recommended COVID-19 testing practices. The facility failed to conduct required COVID-19 testing every seven days for two of four employees sampled, resulting in deficient practice.

Deficiencies (1)
Failure to conduct required COVID-19 testing every seven days for two of four employees sampled.
Report Facts
Facility census: 79 Survey sample: 8 Employees not tested: 2

Employees mentioned
NameTitleContext
E1Nursing Home Administrator (NHA)Reviewed findings during exit conference and responsible for testing tracking log review.
E2Director of Nursing (DON)Interviewed and confirmed employees were not always tested every 3-7 days.
E3Registered Nurse (RN)Worked from 11/21/2020 through 11/30/2020 without being tested for COVID-19.
E4Licensed Practical Nurse (LPN)Worked from 11/6/2020 through 11/17/2020 without being tested for COVID-19.

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