Complete Care At Hillside Llc

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on record review and interview, it was determined that for one (Resident R103) out of three residents reviewed for dignity, the facility failed to ensure that Resident R103 was treated with dignity when staff did not wake

the resident or obtain resident's permission before attempting to provide incontinence care. Findings include: Review of Resident R103's clinical record revealed:8/19/25 - Resident R103 was admitted to the facility with diagnoses including orthostatic hypotension and heart failure.8/25/25 - Resident R103's admission MDS documented a BIMS score of 15, indicating an intact cognition. 8/26/25 - A facility incident report documented, [Resident R103] reported that four days ago [8/22/25] a male aide came into his room and assaulted him by pulling down his underwear. [Resident R103] then said it wasn't his underwear but it was his pants. [Resident R103] unclear [sic] with this allegation and stated that he has been foggy since admitted from [hospital], medications have taken over his mind. [sic] The CNA who cared for [Resident R103] that day was [E16, CNA] .8/26/25 - A follow up facility incident report documented, .[Resident R103] said he was woken up by [E16] was [sic] trying to pull my underwear down to get them off .[Resident R103] denied being touched inappropriately. [Resident R103] said

he didn't want [E16] to take care of him again. [Resident R103] did not want the police called and wasn't fearful .8/29/25 - A facility incident report documented, Statement from [E16] .[E16] adamantly denied this allegation, stating that he did take care of [Resident R103] but did not pull down his underwear or assault him .9/15/25 1:47 PM - Correspondence submitted by E2 (DON) to the State Agency documented, .[E16] was educated as to [sic] customer service explaining why you have entered the room and if you want check the patients for incontinence to let them know that .1/29/26 1:45 PM - During an interview, Resident R103 stated, .I was asleep and felt tugging at my hip. [E16] said that I had to take my underwear off. [E16] did not touch me sexually or anything but he didn't announce himself and he didn't knock on the door .1/29/26 2:11 PM During an interview, E2 stated, No follow up training was given to [E16] after the incident. [E16] only works every other weekend. When [E16] returned the resident was already discharged from the facility.1/30/26 2:30 PM - Findings were reviewed with E1, E2, E13 (Nurse Educator/IP), E20 (ADON) and E21 (Corporate Educator) at the exit conference.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Hillside LLC

810 South Broom Street Wilmington, DE 19805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm

1/29/26 9:15 AM - During an interview, E13 (Nurse Educator/IP) confirmed the openings on the shower bed cushion. The surveyor asked E13 how the shower bed cushion can be disinfected if the plastic is torn and has openings. E13 stated, I will have it removed. 1/30/26 9:00 AM - Finding was reviewed with E1 (NHA).

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Hillside LLC

810 South Broom Street Wilmington, DE 19805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658

The facility lacked evidence that an RN provided Resident R98 any discharge education.

Level of Harm - Minimal harm or potential for actual harm

1/30/26 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON, E13 (Nurse Educator/IP), E20 (ADON) and E21 (Corporate Educator) at the exit conference.

Residents Affected - Few

1. 3. Review of Resident R105's clinical record revealed:

6/27/25 - Resident R105 was admitted to the facility with diagnoses including breast cancer and dementia. 6/27/25 7:15 PM - E24 (LPN) completed a Nursing Admission/Readmission/Annual/Significant Change Assessment form in Resident R105's EMR. 6/27/25 7:15 PM - E24 entered a System Note in Resident R105's clinical record documenting that an admission nursing assessment was completed. 7/8/25 10:45 AM - A facility fall incident report documented, .[Resident R105] found lying on her side in front of her wheelchair .Immediate Action Taken: Neurocheck in effect. Assessment done. Lump noted on left side of [Resident R105's] head .Person Preparing Report: [E23, LPN] . 7/8/25 - A facility document titled, Neurological Evaluation Flow Sheet noted that E23 completed an initial neurological assessment for Resident R105 at 10:45 AM. 1/29/26 11:32 AM - During an interview, E21 (Corporate Educator) stated, The nurse who is assigned to

the resident will do the post fall assessment and any other assessment prompted by entering a change in condition note [in the EMR]. 1/29/26 12:00 PM - Review of a facility staffing document dated 7/8/25 noted that E23 was assigned to Resident R105 at the time the fall occurred. 1/29/26 12:15 PM - During an interview, E23 stated, I don't remember the resident but if I was assigned to a resident that fell and hit their head, I would do a full body assessment and the neuro checks for the shift. 1/29/26 1:00 PM - Review of Resident R105's EMR lacked evidence that an RN completed Resident R105's admission assessment or post fall assessment. 1/30/26 9:00 AM - Finding was reviewed with E1 (NHA). 1/30/26 2:30 PM - Findings were reviewed with E1, E2 (DON), E13 (Nurse Educator/IP) and E21.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Hillside LLC

810 South Broom Street Wilmington, DE 19805

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview, it was determined that for one (Resident R99) out of two residents reviewed for activities of daily living, the facility failed to ensure the dependent resident received his scheduled bathing/showers. Findings include: Review of Resident R99's clinical record revealed: 8/19/25 - Resident R99 was admitted to

the facility. 8/19/25 - Resident R99 was care planned for ADL self-care performance deficit related to a stroke. An intervention was that Resident R99 was totally dependent on staff to provide bath/shower. 8/21/25 - Resident R99 was care planned that it was . important that he has the opportunity to engage in daily routines that are meaningful and relative to his preferences. An intervention for Resident R99 was .very important for [Resident R99's name] to choose how

he [was] bathed. He prefers a shower or bed bath. Review of Resident R99's Documentation Survey Reports from 8/19/25 through 9/4/25 revealed that he was scheduled to be showered or bathed every Wednesday and Saturday evening shift and as needed. Out of five scheduled shower/bathing opportunities documented, Resident R99 received bathing two times and refused bathing one time. Review of Resident R99's progress notes lacked evidence of the reason for no bathing provided on 8/30/25 and 9/3/25. 1/30/26 11:50 AM - E13 (NE/IP) confirmed the finding. 1/30/26 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E13 (NE/IP), E20 (ADON) and E21 (CE).

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet