Complete Care at Hillside LLC

Inspectors wroteBased on observation, interview, and record review, it was determined that for three (second floor, third floor and fourth floor) of three shower rooms, the facility failed to ensure that adequate housekeeping and maintenance services were provided to maintain a clean, sanitary, and home-like environment. Additionally, the hallway carpet on all the units, and the floors of multiple residents' rooms were visibly soiled. Lastly, the facility also failed to ensure that resident care equipment was maintained in good repair and sanitary condition.

Inspectors wroteBased on record review and interview, it was determined that for one (R103) out of three residents reviewed for dignity, the facility failed to ensure that R103 was treated with dignity when staff did not wake the resident or obtain resident's permission before attempting to provide incontinence care.

Inspectors wroteBased on record review and interview, it was determined that for three (R55, R98 and R105) reviewed for care plans, the facility failed to provide care that meets the professional standards of care. For R55 and R105, an LPN completed R55's and R105's admission assessments in violation of the State Board of Nursing Scope of Practice. For R98, there was no evidence of an RN providing discharge education. Additionally, for R105, there was no evidence that an RN completed post fall assessments and documentation. Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024. admission Assessments * - RN. * = Once a care plan is established, the LPN may do assessments. Post Fall Assessment & Documentation ^ - RN .^ = RN must do initial fall assessment; LPN can do subsequent assessments. Discharge Process (RN must do initial teaching) **. ** = LPN can reinforce discharge teaching/plan. [...]

Inspectors wroteBased on record review and interview, it was determined that for one (R99) out of two residents reviewed for activities of daily living, the facility failed to ensure the dependent resident received his scheduled bathing/showers.

Inspectors wroteBased on review of facility policy, record review, observations and interviews, the facility failed to ensure facility infection control procedures were followed related to Transmission Based Precautions (TBP)/Isolation for four Residents (R) R48, R93 and R199 of a total of 47 residents reviewed in the sample. This failure created the potential for residents to become ill related to facility outbreak of infection.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure medications were not left at bedside for a resident that was not assessed to self-administer medications for two resident (Resident (R) 24 and R298) out of 47 residents in the sample. This had the potential to affect all residents who received medications.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure call lights were within reach for one(Residents (R)85) out of a sample of 47 residents reviewed for accommodation of needs and preferences. Specifically, the facility failed to ensure residents had access to their call lights to best assist the residents in maintaining and/or achieving their independent functioning, dignity, and well-being to the extent possible.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to investigate misappropriation of property for two of four residents (Resident (R)84 and R108), This failure has the potential to affect all residents who choose to keep money and/or personal property in their rooms.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop comprehensive care plans related to nebulizer treatment for one resident (Resident (R) 12) out of a total sample of 47 residents. This failure had the potential to negatively impact the resident's quality of life, as well as the quality of care and services received.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure two residents of five residents (Resident (R) 31 and R200) who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene (showers per personal preference) out of a total sample of 47 residents.

Inspectors wroteBased on observation, record review, interview, and review of the facility policy, the facility failed to ensure one of three residents (R)85 reviewed for prevention of skin breakdown, received treatment and interventions according to physician orders out of a total sample of 47 residents. This failure placed the resident at an increased risk for a worsening pressure ulcer, pain, and a decrease in quality of life.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure that a resident with a urinary catheter bag was properly positioned in a manner to prevent potential urinary tract infections due to contamination for one of two residents (R)85 reviewed for urinary catheters and urinary tract infections out of a total sample of 47 residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that one resident (Resident (R) 12) out of 47 sampled residents was provided with the necessary respiratory care and services in accordance with professional standards. This failure had the potential to impact the residents treatment and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received alternative measures prior to installation of side rails for two residents reviewed for side rails (Resident (R) 83 and R298) of 31 sampled residents. The lack of alternate side rail measures could lead to potential safety concerns related to bed rail use for residents with bed rails.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the medical necessity of psychotropic medication administration for one Resident (R)48 of five residents reviewed for Psychotropic Medication Administration and a total of 47 residents reviewed in the sample. Informed consent was not obtained from the resident and/or resident's representative related to administration of psychotropic medication. This failure created the potential for the resident to receive unwanted medications.

Inspectors wroteBased on interview, observations, record review, and review of facility policy, the facility failed to ensure one Resident (R)201 of seven residents reviewed during medication pass observations was free from a significant medication error. The resident's insulin (a medication used to control blood sugar) was not properly administered, creating the potential for the resident to receive an inaccurate dose. A total of 47 residents were reviewed in the sample.

Inspectors wroteBased on interview, observations, record review, and review of facility policy, the facility failed to ensure resident medication stored in facility medication carts was appropriately labeled to indicate the open date of the medication for three Residents (R)47, R110, and R298 out of a total resident sample of 47. This failure created the potential for residents to experience negative effects related to the administration of expired and/or out-of-date medication.

Inspectors wroteBased on interview, record review, facility policy review, the facility failed to ensure that one (Resident (R) 9) of five residents, reviewed for influenza and pneumococcal vaccinations were provided risks verses benefits prior to the administration of the pneumococcal vaccine.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that the room for one resident (Resident (R) 54) of 47 sampled residents was equipped with a functioning call light. This failure had the potential to result in a delayed response to the needs of the resident.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a qualified activity professional was hired. This has the potential to affect the 96 residents' quality of life who currently reside in the facility.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure the resident food stored in the refrigerators in the nourishment rooms on 3 of 3 units was stored in a sanitary manner. This involved 3 of 3 units and had the potential to affect 96 of 98 residents residing in the facility.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the 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. Specifically, the facility failed to ensure donning and doffing procedures, hand hygiene, and isolation precautions were followed according to facility processes to prevent the potential spread of infection to facility residents and staff. This had the potential to affect 98 of 98 residents who resided at the facility.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure call lights were within reach for three residents (Residents (R) 45, 55, and 34) out of a sample of 40 residents reviewed for accommodation of needs and preferences. Specifically, the facility failed to ensure residents had access to their call lights to best assist the resident in maintaining and/or achieving their independent functioning, dignity, and well-being to the extent possible.

Inspectors wroteBased on record review, review of facility policy, review of the Resident Assessment Instrument (RAI) manual, and staff interviews, the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for one of 40 sampled residents (Resident (R) R87) reviewed for care plans. Specifically, R87 did not have a Care Plan to address Post Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on record review and staff interview, the facility failed to accurately assess one resident after an unwitnessed fall and failed to put additional interventions in place to prevent future falls for one of three (Resident 10 (R10)) sampled residents reviewed for falls.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to obtain a physician's order for the use of oxygen for one of four residents (Resident (R) 2) reviewed for oxygen therapy out of a total sample of 40 residents.

Inspectors wroteBased on record review of one (R1) out three residents sampled for care plans, the facility failed to implement a care plan for R1's use of oxygen.

Inspectors wroteBased on interview and record review it was determined that for one (R1) out of three residents reviewed for care, the facility failed to ensure that R1 received treatment and care in accordance with professional standards of practice and physician orders. On the evening of 11/14/23 R1 had a change in condition and became unresponsive in the facility and was transported to an acute care hospital without a nursing assesment including vital signs.

Inspectors wroteBased on record review and interview, it was determined that for one (R1) out of three residents reviewed for Staffing, the facility failed to provide competent nursing care that included assessments and interventions for a resident who experienced a change in respiratory condition.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that food was stored, prepared, and served in a sanitary manner.

Inspectors wroteBased on record review and interview, it was determined that for one (R28) out of 19 resident in the investigative sample, the facility failed to develop comprehensive care plans for identified resident care areas.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that for one (R60) out of two residents reviewed for hospitalizations received medication as ordered by the physician.

Inspectors wroteBased on interview and review of the clinical record and the facility's policy and procedure, it was determined that for one (R80) out of two residents sampled for Coumadin medication review, the facility failed to ensure that R80's 1/3/22 lab result was received and reviewed by the physician.

Inspectors wroteBased on observations, clinical record review and interviews, it was determined that the facility failed to ensure that the physician's order for one resident (R79) was followed during a random dining observation.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the Ombudsman was notified of a hospital transfer or facility discharge for two (R60 and R92) out of two residents sampled for hospitalization.