Cycle 1
Health 2024-10-31 · Fire 2024-10-31
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Dover, DE
Westminster Village Health
4-star overall rating with 3-star inspections with $38,518 in total fines with 11 recent health deficiencies
1175 Mckee Road, Dover, DE
(302) 744-3527
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
65
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Senior Living
Operator or chain grouping
Approved since
1987-02-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 4 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
1.03
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
37%
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
7,904
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.75% · Performance 22.24% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.19% · Performance 8.27% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.05
Baseline 34.78% · Performance 30.77% · Measure score 8.05 · Achievement 8.05 · Improvement 3.54
Adjusted total nurse staffing
3.32
Baseline 4.21 hours · Performance 4.02 hours · Measure score 3.32 · Achievement 3.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.76% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 159 · Observed rate 12.58% · Lower 95% interval 8.81% |
| Discharge to community | 43.48% |
50.57%
7.1 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 38.36% · Lower 95% interval 36.2% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 91 · Denominator 91 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 91 |
| Discharge self-care score | 47.06% |
53.69%
6.6 pts worse
|
Numerator 32 · Denominator 68 |
| Discharge mobility score | 30.88% |
50.94%
20.1 pts worse
|
Numerator 21 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 4.4% |
2.29%
2.1 pts worse
|
Numerator 4 · Denominator 91 · Adjusted rate 4.46% |
| Healthcare-associated infections requiring hospitalization | 8.27% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 108 · Observed rate 9.26% · Lower 95% interval 4.74% |
| Staff COVID-19 vaccination coverage | 34.15% |
8.2%
25.9 pts better
|
Numerator 42 · Denominator 123 |
| Staff flu vaccination coverage | 46.62% |
42%
4.6 pts better
|
Numerator 62 · Denominator 133 |
| Discharge function score | 36.76% |
56.45%
19.7 pts worse
|
Numerator 25 · Denominator 68 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 44.07% |
25.2%
18.9 pts better
|
Numerator 26 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| 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 · Adjusted 1.1 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 59.0% |
95.7%
36.7 pts worse
|
93.4%
34.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.7% · Q2 57.4% · Q3 55.6% · Q4 61.4% · 4Q avg 59.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.0% |
97.4%
9.4 pts worse
|
95.5%
7.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.6% · Q4 5.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 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 who lose too much weight | 5.3% |
5.6%
0.3 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 0.0% · Q3 7.0% · Q4 6.5% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.2% |
21.1%
14.9 pts better
|
19.6%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 2.5% · Q3 8.9% · Q4 2.1% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
12.0%
4.1 pts better
|
16.7%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.9% · Q3 11.4% · Q4 8.1% · 4Q avg 7.9% · 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 | 29.6% |
17.5%
12.1 pts worse
|
16.3%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
14.7%
4.7 pts worse
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 11.4% · Q3 7.1% · Q4 25.0% · 4Q avg 19.4% · 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 | 0.5% |
2.0%
1.5 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.8% |
21.6%
4.8 pts better
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 18.8% · Q3 13.8% · Q4 24.0% · 4Q avg 16.8% |
| 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 5.1% · Q2 1.7% · Q3 1.4% · Q4 1.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 27.6% |
83.5%
55.9 pts worse
|
81.7%
54.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 29.8% · Q3 27.7% · Q4 21.9% · 4Q avg 27.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
11.2%
1.9 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 8.5% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
0.9%
0.8 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 1.8% · Q4 4.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
83.1%
33.1 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
21.5%
0.3 pts worse
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 21.7% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-01 · Fire 2023-11-01
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-12-20 · Fire 2021-12-20
9 health deficiencies
Top issue: Quality of Life and Care (7 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
2023-11-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-11-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-16
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 2026-01-22
D · Potential for more than minimal harm
2025-12-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-22
J · Immediate jeopardy
2025-10-08
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 2025-10-01
E · Potential for more than minimal harm
2024-10-31
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 2024-12-09
D · Potential for more than minimal harm
2024-10-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-10-31
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 2024-12-09
D · Potential for more than minimal harm
2024-10-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-10-31
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 2024-12-09
D · Potential for more than minimal harm
2024-10-31
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 2024-12-09
C · Minimal harm
2024-10-31
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 2024-12-09
D · Potential for more than minimal harm
2024-09-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-02
D · Potential for more than minimal harm
2024-09-16
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 2024-10-02
J · Immediate jeopardy
2023-11-01
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 2022-12-16
F · Potential for more than minimal harm
2023-11-01
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 2024-01-03
E · Potential for more than minimal harm
2023-11-01
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 2024-01-03
D · Potential for more than minimal harm
2023-11-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-01
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 2024-01-03
D · Potential for more than minimal harm
2023-11-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-01
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 2024-01-03
D · Potential for more than minimal harm
2023-11-01
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 2024-01-03
D · Potential for more than minimal harm
2023-11-01
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 2024-01-03
D · Potential for more than minimal harm
2023-11-01
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-01
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 2024-01-03
G · Actual harm
2021-12-20
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 2022-03-01
D · Potential for more than minimal harm
2021-12-20
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 2022-03-01
D · Potential for more than minimal harm
2021-12-20
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 2022-03-01
D · Potential for more than minimal harm
2021-12-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-03-01
D · Potential for more than minimal harm
2021-12-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-01
D · Potential for more than minimal harm
2021-12-20
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 2022-03-01
D · Potential for more than minimal harm
2021-12-20
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 2022-03-01
Penalties and ownership
What sits behind the stars
$22,925
2025-10-08
Fine
Fine · fine $22,925
Fine
$15,593
2023-11-01
Fine
Fine · fine $15,593
Fine
Ownership
Phi
5% Or Greater Direct Ownership Interest · Organization
Birdsall, James
Corporate Director · Individual
Bowser, Nicole
W-2 Managing Employee · Individual
Chottiner, Lawrence
Corporate Director · Individual
Davis, Danny
Corporate Officer · Individual
Elliott, Brenda
Corporate Director · Individual
Goldstein, Terry
Corporate Director · Individual
Hoffman, Cynthia
Corporate Officer · Individual
Kelly, Sharon
Corporate Director · Individual
Kinard, Joseph
Corporate Director · Individual
Kinard, Joseph
Corporate Officer · Individual
Krieger, Daniel
Corporate Officer · Individual
Mcalister, Dyan
Corporate Officer · Individual
Paxton, Stuart
Corporate Director · Individual
Reimann, Susan
Corporate Director · Individual
Reimann, Susan
Corporate Officer · Individual
Rhodes, Cheryl
Corporate Director · Individual
Scott, William
Corporate Director · Individual
Seibert, Joseph
Corporate Director · Individual
Shropshire, Jennifer
Corporate Director · Individual
Stone, Robyn
Corporate Director · Individual
Vinette-Clay, Melissa
W-2 Managing Employee · Individual
Wickline, Beverly
Corporate Officer · Individual
Nearby options
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#2
Complete Care At Silver Lake LLC
Dover, DE
3-star overall rating with 2-star inspections with $47,541 in total fines with 15 recent health deficiencies
#3
Center At Eden Hill, LLC
Dover, DE
5-star overall rating with 5-star inspections with 8 recent health deficiencies
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