Cycle 1
Health 2025-02-19 · Fire 2025-02-19
18 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Dover, DE
Bay Terrace Rehabilitation And Health Center
3-star overall rating with 3-star inspections with $19,937 in total fines with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
889 South Little Creek Road, Dover, DE
(302) 674-0566
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
77
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
1979-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 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
1.02
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,935
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.92% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.92% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.54
Baseline 36.07% · Performance 41.03% · Measure score 5.54 · Achievement 5.54 · Improvement 0
Adjusted total nurse staffing
4.55
Baseline 4.44 hours · Performance 4.37 hours · Measure score 4.55 · Achievement 4.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.82% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 11.54% · Lower 95% interval 6.86% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.06% |
95.27%
1.8 pts better
|
Numerator 66 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 57.89% |
53.69%
4.2 pts better
|
Numerator 22 · Denominator 38 |
| Discharge mobility score | 44.74% |
50.94%
6.2 pts worse
|
Numerator 17 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 2.94% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 68 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 8.92% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 16.22% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 1.14% |
8.2%
7.1 pts worse
|
Numerator 2 · Denominator 176 |
| Staff flu vaccination coverage | 28.11% |
42%
13.9 pts worse
|
Numerator 52 · Denominator 185 |
| Discharge function score | 55.26% |
56.45%
1.2 pts worse
|
Numerator 21 · Denominator 38 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 24 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 53.33% |
25.2%
28.1 pts better
|
Numerator 16 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.4
About the same
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
95.7%
3.5 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.5% · Q3 100.0% · Q4 98.4% · 4Q avg 99.2% |
| 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 | 2.8% |
3.2%
0.4 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.0% · Q3 3.3% · Q4 3.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.6% |
6.5%
1.1 pts worse
|
11.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 14.8% · Q4 16.7% · 4Q avg 7.6% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.6%
3 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 0.0% · Q3 0.0% · Q4 3.5% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.3% |
21.1%
16.8 pts better
|
19.6%
15.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.8% · Q3 5.4% · Q4 3.4% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
12.0%
4.9 pts worse
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 22.7% · Q3 9.3% · Q4 4.7% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.4% |
0.1%
0.3 pts worse
|
0.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.5% |
17.5%
8 pts better
|
16.3%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 7.7% · Q3 5.9% · Q4 5.7% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.7% |
14.7%
3 pts better
|
14.9%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 11.1% · Q3 14.9% · Q4 6.1% · 4Q avg 11.7% · 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 | 20.5% |
21.6%
1.1 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 22.2% · Q3 10.2% · Q4 21.6% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.4%
2.1 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.6% · Q3 1.3% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
83.5%
14.8 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
11.2%
0.8 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 10.1% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
0.9%
0.5 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
83.1%
14.9 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
21.5%
3.6 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 27.5% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
14 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-26 · Fire 2022-09-26
4 health deficiencies
Top issue: Quality of Life and Care (3 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
2025-02-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-02-19
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 2025-04-10
D · Potential for more than minimal harm
2025-02-19
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 2025-04-10
D · Potential for more than minimal harm
2025-02-19
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-19
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 2025-04-10
D · Potential for more than minimal harm
2025-02-19
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-19
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 2025-04-10
D · Potential for more than minimal harm
2025-02-19
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 2025-04-10
D · Potential for more than minimal harm
2025-02-19
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 2025-04-10
D · Potential for more than minimal harm
2025-02-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-19
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 2025-04-10
D · Potential for more than minimal harm
2025-02-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-19
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 2025-04-10
D · Potential for more than minimal harm
2025-02-19
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-04-10
C · Minimal harm
2025-02-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-04-10
G · Actual harm
2024-12-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-02
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-02
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-02
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 2025-01-20
E · Potential for more than minimal harm
2024-02-23
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 2024-04-01
E · Potential for more than minimal harm
2024-02-23
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-23
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 2024-04-01
E · Potential for more than minimal harm
2024-02-23
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
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 2024-04-01
D · Potential for more than minimal harm
2024-02-23
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-23
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-04-01
E · Potential for more than minimal harm
2022-09-26
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 2022-10-18
D · Potential for more than minimal harm
2022-09-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-18
Penalties and ownership
What sits behind the stars
$9,113
2025-04-11
Fine
Fine · fine $9,113
Fine
$10,824
2024-12-02
Fine
Fine · fine $10,824
Fine
Ownership
Btrc Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Aysan Tr
5% Or Greater Indirect Ownership Interest · Organization
Buah Trust
5% Or Greater Indirect Ownership Interest · Organization
Copper De Trust
5% Or Greater Indirect Ownership Interest · Organization
Ellenbogen, Moss
Operational/Managerial Control · Individual
Gold De Trust
5% Or Greater Indirect Ownership Interest · Organization
Pa & De Noble Parentco LLC
5% Or Greater Indirect Ownership Interest · Organization
Silver De Trust
5% Or Greater Indirect Ownership Interest · Organization
Star De I Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Star De I Trust
5% Or Greater Indirect Ownership Interest · Organization
Studd, Anne
Operational/Managerial Control · Individual
Nearby options
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#3
Cadia Rehabilitation Capitol
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3-star overall rating with 3-star inspections with $8,018 in total fines with 9 recent health deficiencies
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