Complete Care At Hillside Llc
COMPLETE CARE AT HILLSIDE LLC in WILMINGTON, DE — inspection on January 30, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based 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.
Findings include: Review of R103's clinical record revealed:8/19/25 - R103 was admitted to the facility with diagnoses including orthostatic hypotension and heart failure.8/25/25 - R103's admission MDS documented a BIMS score of 15, indicating an intact cognition. 8/26/25 - A facility incident report documented, [R103] reported that four days ago [8/22/25] a male aide came into his room and assaulted him by pulling down his underwear. [R103] then said it wasn't his underwear but it was his pants. [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 [R103] that day was [E16, CNA] .8/26/25 - A follow up facility incident report documented, .[R103] said he was woken up by [E16] was [sic] trying to pull my underwear down to get them off .[R103] denied being touched inappropriately. [R103] said he didn't want [E16] to take care of him again. [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 [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, 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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Hillside LLC
810 South Broom Street Wilmington, DE 19805
SUMMARY STATEMENT OF DEFICIENCIES
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).
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Hillside LLC
810 South Broom Street Wilmington, DE 19805
SUMMARY STATEMENT OF DEFICIENCIES
Review of R105's clinical record revealed: 6/27/25 - 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 R105's EMR. 6/27/25 7:15 PM - E24 entered a System Note in R105's clinical record documenting that an admission nursing assessment was completed. 7/8/25 10:45 AM - A facility fall incident report documented, .[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 [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 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 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 R105's EMR lacked evidence that an RN completed 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Hillside LLC
810 South Broom Street Wilmington, DE 19805
SUMMARY STATEMENT OF DEFICIENCIES
Based 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.
Findings include: Review of R99's clinical record revealed: 8/19/25 - R99 was admitted to the facility. 8/19/25 - R99 was care planned for ADL self-care performance deficit related to a stroke. An intervention was that R99 was totally dependent on staff to provide bath/shower. 8/21/25 - 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 R99 was .very important for [R99's name] to choose how he [was] bathed. He prefers a shower or bed bath.
Review of 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, R99 received bathing two times and refused bathing one time.
Review of 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).
Facility ID: