Inspection Reports for Complete Care at Hillside LLC
810 South Broom Street, Wilmington, DE, 19805
Back to Facility ProfileInspection 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 are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a February 2025 inspection.
Census over time
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| LPN7 | Licensed Practical Nurse | Observed administering insulin incorrectly and interviewed about insulin pen use |
| LPN8 | Licensed Practical Nurse | Interviewed about insulin pens lacking open/discard dates |
| LPN9 | Licensed Practical Nurse | Interviewed about insulin pens lacking open/discard dates |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication consent and infection control |
| Administrator | Administrator | Interviewed regarding multiple deficiencies including medication consent, infection control, and call light issues |
| Infection Preventionist | Infection Preventionist/Educator Nurse Practice | Interviewed regarding infection control and insulin pen labeling |
| LPN4 | Licensed Practical Nurse | Interviewed regarding wound care and medication orders |
| LPN5 | Licensed Practical Nurse | Interviewed regarding wound care and catheter bag positioning |
| LPN6 | Licensed Practical Nurse | Interviewed regarding catheter bag positioning and bed rail consent |
| Activity Director | Activity Director | Interviewed regarding qualifications and certification status |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| R24 | Resident involved in medication self-administration deficiency. | |
| R298 | Resident involved in medication self-administration deficiency. | |
| Director of Nursing | DON | Observed medication deficiencies and conducted audits. |
| Licensed Practical Nurse 4 | LPN 4 | Observed call light placement deficiency. |
| Licensed Practical Nurse 5 | LPN 5 | Involved in wound care and insulin pen labeling deficiencies. |
| Certified Nurse Aide 1 | CNA1 | Involved in abuse investigation. |
| Administrator | Provided statements and education related to deficiencies. | |
| Assistant Director of Nursing | ADON | Conducted audits and education related to nebulizer treatments. |
| Licensed Practical Nurse 3 | LPN 3 | Observed nebulizer medication administration. |
| Licensed Practical Nurse 6 | LPN 6 | Observed catheter bag placement. |
| Licensed Practical Nurse 7 | LPN 7 | Observed respiratory symptoms and insulin pen administration. |
| Licensed Practical Nurse 8 | LPN 8 | Failed to label insulin pens properly. |
| Licensed Practical Nurse 9 | LPN 9 | Observed insulin pen administration. |
| Infection Preventionist/Educator Nurse Practice | IP/ENP | Provided infection control education and observations. |
| Resource Nurse | Addressed shower/bath documentation issues. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| LPN 14 | Licensed Practical Nurse | Conducted fall risk assessment and was interviewed about Resident 10's fall |
| LPN 11 | Licensed Practical Nurse | Interviewed regarding PPE doffing and infection control practices |
| RN 15 | Registered Nurse | Signed nursing progress note related to Resident 10's fall |
| Director of Nursing | Director of Nursing | Interviewed about fall and infection control practices |
| CNA 20 | Certified Nurse Aide | Observed donning and doffing PPE in COVID-19 isolation room |
| CNA 2 | Certified Nursing Assistant | Observed emptying urinals without gloves on Resident 64 |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control education and PPE compliance |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 13 | LPN | Observed call light accessibility issues and confirmed deficiencies |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan responsibilities and knowledge of PTSD care plan |
| Director of Nursing | DON | Interviewed regarding care plan oversight, fall risk assessment, oxygen orders, and infection control |
| Licensed Practical Nurse 14 | LPN | Interviewed regarding fall incident and assessment |
| Certified Nursing Assistant 6 | CNA | Interviewed regarding call light accessibility and infection control observations |
| Certified Nursing Assistant 9 | CNA | Interviewed regarding call light accessibility and infection control observations |
| Certified Nursing Assistant 20 | CNA | Observed donning and doffing PPE in COVID-19 isolation room |
| Licensed Practical Nurse 11 | LPN | Interviewed regarding oxygen therapy orders and infection control practices |
| Certified Nursing Assistant 2 | CNA | Observed and interviewed regarding improper glove use during urinal emptying |
| Infection Preventionist | IP | Interviewed regarding infection control education, PPE compliance, and isolation practices |
| Corporate Dietary Manager 27 | CDM | Assisted with refrigerator inspections and verified food storage deficiencies |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 13 | Licensed Practical Nurse | Observed call light button accessibility issues for resident R45 |
| Licensed Practical Nurse 14 | Licensed Practical Nurse | Interviewed regarding resident R10 fall and oxygen use |
| Director of Nursing | Director of Nursing | Interviewed regarding call light accessibility and fall prevention |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plans for residents |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Interviewed regarding care plan knowledge for resident R87 |
| Certified Nursing Assistant 6 | Certified Nursing Assistant | Interviewed regarding oxygen management |
| Certified Nursing Assistant 9 | Certified Nursing Assistant | Interviewed regarding oxygen management |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| E3 | RN Supervisor | Named in failure to assess resident R1 during change in condition and calling 911 |
| E1 | NHA (Nursing Home Administrator) | Reviewed findings with surveyors |
| E2 | DON (Director of Nursing) | Reviewed findings with surveyors |
| E5 | Staff Educator | Interviewed regarding nursing orientation and emergency cart training |
| E4 | Regional Clinical Consultant | Reviewed findings with surveyors |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Reviewed findings with surveyors |
| E2 | Director of Nursing (DON) | Reviewed findings with surveyors |
| E3 | RN Supervisor | Involved in resident care and interviews related to deficiencies |
| E4 | Regional Clinical Consultant | Reviewed findings with surveyors |
| E5 | Staff Educator (RN) | Interviewed regarding nursing orientation and emergency cart training |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| E1 | NHA | Confirmed failure to notify Ombudsman and reviewed findings during Exit Conference. |
| E2 | DON | Reviewed findings during Exit Conference. |
| E3 | ADON | Confirmed no care plan for oxygen use. |
| E4 | RN | Unable to locate INR lab result and contacted lab company. |
| E5 | FSD | Confirmed dietary findings and food service deficiencies. |
| E6 | NPE/Staff Developer | Reviewed findings and interviewed regarding infection control and medication administration. |
| E7 | RD | Confirmed dietary order was not followed during dining observation. |
| E8 | LPN | Uncertain if provider was notified about medication unavailability. |
| E9 | RN | Transcribed and discontinued antibiotic orders for R60. |
| E10 | Regional Clinical Consultant | Reviewed findings during Exit Conference. |
| E11 | Complete Care Representative | Reviewed findings during Exit Conference. |
| E12 | Nurse Practitioner | Confirmed expectation to be notified when medication was unavailable. |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| E14 | Certified Nurse's Aide (CNA) | Reported observation of alleged verbal abuse |
| E15 | Certified Nurse's Aide (CNA) | Confirmed report of alleged verbal abuse |
| E1 | Nursing Home Administrator (NHA) | Reviewed findings and participated in exit conference |
| E2 | Director of Nursing (DON) | Reviewed findings and participated in exit conference |
| E3 | Assistant Director of Nursing (ADON) | Confirmed no care plan for oxygen use |
| E5 | Food Service Director (FSD) | Confirmed dietary findings |
| E6 | Nurse Practice Educator (NPE)/Staff Developer | Reviewed findings and participated in exit conference |
| E7 | Registered Dietitian (RD) | Confirmed dietary findings |
| E8 | Licensed Practical Nurse (LPN) | Interviewed regarding medication availability |
| E10 | Regional Clinical Consultant | Reviewed findings and participated in exit conference |
| E11 | Complete Care Representative | Reviewed findings and participated in exit conference |
| E12 | Nurse Practitioner | Interviewed regarding medication notification expectations |
| E13 | Physician | Acknowledged lab monitoring deficiencies |
| E4 | Registered Nurse (RN) | Interviewed regarding lab result receipt |
| E9 | Registered Nurse (RN) | Received hospital order and transcribed medication order |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Reviewed findings during exit conference and responsible for testing tracking log review. |
| E2 | Director of Nursing (DON) | Interviewed and confirmed employees were not always tested every 3-7 days. |
| E3 | Registered Nurse (RN) | Worked from 11/21/2020 through 11/30/2020 without being tested for COVID-19. |
| E4 | Licensed Practical Nurse (LPN) | Worked from 11/6/2020 through 11/17/2020 without being tested for COVID-19. |
Loading inspection reports...



