Cycle 1
Health 2025-01-23 · Fire 2025-01-23
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Dover, DE
Complete Care At Silver Lake LLC
3-star overall rating with 2-star inspections with $47,541 in total fines with 15 recent health deficiencies
1080 Silver Lake Blvd, Dover, DE
(302) 734-5990
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
120
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1984-05-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing
LPN hours / resident day
0.71
Licensed practical nurse staffing
Aide hours / resident day
2.37
Nurse aide staffing
Weekend hours
3.67
Weekend nurse staffing
RN turnover
44%
Annual RN turnover
Total nurse turnover
36%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.4
0.3 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
95.7%
4.1 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.2%
2.5 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 55.2% |
6.5%
48.7 pts worse
|
11.4%
43.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.3% |
5.6%
2.7 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
21.1%
3 pts better
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
12.0%
1.9 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.3% |
17.5%
9.2 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
14.7%
4.5 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.7%
About the same
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.0%
1.7 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
21.6%
1.7 pts better
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
4.4%
3 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
83.5%
10.3 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
11.2%
0.6 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
0.9%
2.8 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
83.1%
12.3 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.1% |
21.5%
3.4 pts better
|
23.9%
5.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-12 · Fire 2024-02-12
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
11 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
2024-02-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-25
E · Potential for more than minimal harm
2024-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-25
E · Potential for more than minimal harm
2024-02-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-23
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 2026-03-11
D · Potential for more than minimal harm
2026-01-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-03-11
D · Potential for more than minimal harm
2026-01-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-03-11
G · Actual harm
2025-01-23
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 2025-03-06
F · Potential for more than minimal harm
2025-01-23
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 2025-03-06
F · Potential for more than minimal harm
2025-01-23
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-03-06
E · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-23
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 2025-03-06
D · Potential for more than minimal harm
2025-01-23
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-23
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-23
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-06
E · Potential for more than minimal harm
2024-02-12
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 2024-03-06
D · Potential for more than minimal harm
2024-02-12
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 2024-03-06
D · Potential for more than minimal harm
2024-02-12
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 2024-03-06
D · Potential for more than minimal harm
2024-02-12
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 2024-03-06
D · Potential for more than minimal harm
2024-02-12
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-06
C · Minimal harm
2024-02-12
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 2024-03-06
G · Actual harm
2022-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-09
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 2023-01-23
E · Potential for more than minimal harm
2022-12-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-09
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-09
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 2023-01-23
D · Potential for more than minimal harm
2022-12-09
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 2023-01-23
D · Potential for more than minimal harm
2022-12-09
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 2023-01-23
D · Potential for more than minimal harm
2022-12-09
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 2023-01-23
D · Potential for more than minimal harm
2022-12-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-09
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-01-23
Penalties and ownership
What sits behind the stars
$47,541
2025-01-23
Fine
Fine · fine $47,541
Fine
Ownership
Pc De Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Cox, Vickie
Operational/Managerial Control · Individual
Mansfield, Melissa
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
Rastogi, Ritu
Operational/Managerial Control · Individual
Silverberg, Nisanel
Operational/Managerial Control · Individual
Smith, Steven
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
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#3
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