Inspection Reports for Complete Care at Hillside LLC

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.