Map showing the location of COMPLETE CARE AT SILVER LAKE LLC in DOVER, Delaware
1080 SILVER LAKE BLVD, DOVER, DE, 19904

Overall Score

CMS Five-Star Quality Rating
4/5Above averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • DelawareAbove 55% of peers43 rated homes · average 3.3★
  • Kent CountyAbove 50% of peers7 rated homes · average 3.7★
  • United StatesAbove 61% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.3 vs DE avg
  • StaffingCan add or remove a star4★±0.0 vs DE avg
  • Quality measuresCan add or remove a star5★+0.8 vs DE avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above 57% of peersDE avg2.7★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 26% of peersDE avg4.0★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above only 48% of peersDE avg4.2★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.05hrsAbove 58% of peersDE avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.96hrsAbove 65% of peersDE avg1.03Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better36%Above 72% of peersDE avg42%RN turnover44%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$47,541Above only 35% of peersDE avg$66,380Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
29citations
3inspection dates
2actual harm (G–I)
0immediate jeopardy (J–L)
Jan 23, 2025most recent

Citations by monthDec 2022 – Jan 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jan 23, 202512 citationsCycle 1worst G · actual harm$47,541
  1. F881Implement a program that monitors antibiotic use.Infection ControlF · widespreadCorrected Mar 6, 2025
  2. 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.Resident RightsD · isolatedCorrected Mar 6, 2025
  3. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Mar 6, 2025
  4. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 6, 2025
  5. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 6, 2025
  6. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Mar 6, 2025
  7. F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Mar 6, 2025
  8. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Mar 6, 2025
  9. F742Provide 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.Quality of Life and CareD · isolatedCorrected Mar 6, 2025
  10. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryD · isolatedCorrected Mar 6, 2025
  11. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 6, 2025
  12. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 6, 2025
Feb 12, 20247 citationsCycle 2worst E · no actual harm
  1. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Mar 6, 2024
  2. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Mar 6, 2024
  3. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 6, 2024
  4. F688Provide 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.Quality of Life and CareD · isolatedCorrected Mar 6, 2024
  5. F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Mar 6, 2024
  6. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Mar 6, 2024
  7. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceC · widespreadCorrected Mar 6, 2024
Dec 9, 202210 citationsCycle 3worst G · actual harm
  1. F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 23, 2023
  2. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Jan 23, 2023
  3. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jan 23, 2023
  4. F688Provide 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.Quality of Life and CareD · isolatedCorrected Jan 23, 2023
  5. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Jan 23, 2023
  6. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Jan 23, 2023
  7. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Jan 23, 2023
  8. F803Ensure 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.Nutrition and DietaryD · isolatedCorrected Jan 23, 2023
  9. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jan 23, 2023
  10. F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Jan 23, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.05hrsAbove 58% of peers−0.46 vs DE avg
  • Registered nursesRN hours only0.96hrsAbove 65% of peers−0.07 vs DE avg
  • Licensed practical nursesLPN hours0.71hrs
  • Nurse aidesCNA hours2.37hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.67hrs
  • Delaware average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better36%Above 72% of peersDE avg 42%
  • RN turnoverRegistered nurses only44%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy120 certified beds · ~116 residents a day97%Top 2%DE avg 81%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $47,541In fines
  • 1Fine
  • 0Payment denials
  • $66,380DE avg in fines
Above only 35% of peersFewer fines than 35% of rated homes in Delaware

Actions on record

  1. Jan 23, 2025Civil money penalty$47,541

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Complete Care85 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Pc de Opcos LLC
Indirect owners (5%+)
  • Pc Wta Opco Holdco LLC
  • Peace Capital Holdings LLC (De)
  • Sms 2021 Trust
Operational or managerial control
  • Vickie Cox
  • Melissa Mansfield
  • Ritu Rastogi
  • Nisanel Silverberg
  • Steven Smith
Corporate officers
  • Shalom Stein
5% Or Greater Security Interest
  • Welltower Op LLC

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 085027 · 1080 SILVER LAKE BLVD, DOVER, DE, 19904.
  • Percentiles compare this facility with every rated nursing home in Delaware and Kent County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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