Inspection Reports for
Complete Care at Hillside LLC

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.

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.

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 facility was found deficient in multiple areas including medication management, resident care plans, infection control, respiratory care, pressure ulcer care, call light functionality, and psychotropic medication consent. Several residents were affected by issues such as improper medication storage, inadequate care planning, failure to implement isolation precautions timely, and unsafe catheter and wound care.

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.

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.

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.

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.

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 investigation was complaint-driven, focusing on falls and infection control issues. The fall complaint was substantiated with findings of inaccurate fall risk assessment and lack of intervention changes. Infection control deficiencies were observed through multiple staff observations and interviews.

The facility failed to accurately assess a resident after an unwitnessed fall and did not implement additional interventions to prevent future falls. The facility also failed to maintain an effective infection prevention and control program, including improper donning and doffing of PPE, inadequate hand hygiene, and failure to follow isolation precautions, potentially affecting all residents.

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

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.

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.

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.

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 complaint investigation focused on the facility's failure to implement a care plan for oxygen use and failure to provide appropriate nursing care during a resident's change in condition. The complaint was substantiated with findings of inadequate care and training.

The facility failed to implement a care plan for resident R1's continuous oxygen use and did not provide appropriate assessments or interventions during a respiratory emergency. The nurse on duty lacked complete training on emergency equipment use, and the resident was transported to the hospital without proper nursing assessment.

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.

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.

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 visit was complaint-related, investigating failures in notification to the Ombudsman, care planning, medication administration, lab result review, dietary compliance, and food sanitation. Substantiation status is not explicitly stated.

The facility failed to notify the Ombudsman of hospital transfers for two residents, did not develop comprehensive care plans for one resident, failed to administer medication as ordered for one resident, did not ensure lab results were reviewed by the physician for one resident, failed to follow a prescribed therapeutic diet for one resident, and did not maintain sanitary food storage and preparation conditions.

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.

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.