Cycle 1
Health 2025-02-06 · Fire 2025-02-06
20 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wilmington, DE
Complete Care At Hillside LLC
4-star overall rating with 3-star inspections with 20 recent health deficiencies
810 South Broom Street, Wilmington, DE
(302) 652-1181
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1970-11-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.95
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,169
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.31
Baseline 19.99% · Performance 19.43% · Measure score 4.31 · Achievement 4.31 · Improvement 1.39
Healthcare-associated infections
0
Baseline 7.15% · Performance 7.84% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.84
Baseline 47.37% · Performance 43.88% · Measure score 4.84 · Achievement 4.84 · Improvement 1.05
Adjusted total nurse staffing
1.89
Baseline 3.82 hours · Performance 3.61 hours · Measure score 1.89 · Achievement 1.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 12.5% · Lower 95% interval 7.18% |
| Discharge to community | 53.92% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 42.62% · Lower 95% interval 41.94% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 86 · Denominator 86 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 86 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 15 · Denominator 20 |
| Discharge mobility score | 75% |
50.94%
24.1 pts better
|
Numerator 15 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 3.49% |
2.29%
1.2 pts worse
|
Numerator 3 · Denominator 86 · Adjusted rate 3.39% |
| Healthcare-associated infections requiring hospitalization | 7.84% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 11.27% · Lower 95% interval 5.06% |
| Staff COVID-19 vaccination coverage | 5.68% |
8.2%
2.5 pts worse
|
Numerator 5 · Denominator 88 |
| Staff flu vaccination coverage | 71.43% |
42%
29.4 pts better
|
Numerator 105 · Denominator 147 |
| Discharge function score | 70% |
56.45%
13.5 pts better
|
Numerator 14 · Denominator 20 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 64 · Denominator 64 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 52% |
25.2%
26.8 pts better
|
Numerator 26 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
95.7%
2.7 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.4%
2.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.2% · Q3 1.3% · Q4 2.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
6.5%
4.4 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.9% · Q4 4.5% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.6%
0.1 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 4.0% · Q3 2.9% · Q4 4.8% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
21.1%
5 pts better
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 13.2% · Q3 18.8% · Q4 16.9% · 4Q avg 16.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.7% |
12.0%
3.7 pts worse
|
16.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 13.1% · Q3 19.3% · Q4 15.1% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.3% |
17.5%
13.2 pts better
|
16.3%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 11.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.5% |
14.7%
12.2 pts better
|
14.9%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 3.0% · Q4 3.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
21.6%
4.2 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 29.1% · Q3 26.8% · Q4 23.4% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.4%
1.3 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.3% · Q3 2.4% · Q4 4.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
83.5%
13.5 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 98.4% · Q3 99.2% · Q4 94.5% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
11.2%
0.3 pts worse
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 12.0% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
83.1%
16.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
21.5%
2.6 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 32.0% · Expected 31.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-01-19 · Fire 2022-01-19
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-03-16
D · Potential for more than minimal harm
2026-01-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-03-16
D · Potential for more than minimal harm
2026-01-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-03-16
D · Potential for more than minimal harm
2026-01-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-03-16
E · Potential for more than minimal harm
2025-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-12
C · Minimal harm
2025-02-06
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2025-03-12
F · Potential for more than minimal harm
2024-02-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-09
F · Potential for more than minimal harm
2024-02-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-09
D · Potential for more than minimal harm
2023-11-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-12-20
F · Potential for more than minimal harm
2022-01-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-01-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-01-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-01-19
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-01-19
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2022-02-25
B · Minimal harm
2022-01-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-02-25
Penalties and ownership
What sits behind the stars
Ownership
Pc De Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Baich-Pietlock, Debra
Operational/Managerial Control · Individual
Cox, Vickie
Operational/Managerial Control · Individual
Graziano, Ruth
Operational/Managerial Control · Individual
Mansfield, Melissa
Operational/Managerial Control · Individual
Mcghee, Karen
Operational/Managerial Control · Individual
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Silverberg, Nisanel
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Welltower Inc
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Regency Healthcare & Rehab Center
Wilmington, DE
4-star overall rating with 4-star inspections with $226,471 in total fines with 2 recent health deficiencies
#2
Excelcare At Wilmington LLC
Wilmington, DE
3-star overall rating with 2-star inspections with abuse icon flag with $38,290 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Gilpin Hall
Wilmington, DE
3-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies
Jump out