DOVER, DE - Federal inspectors identified multiple health and safety violations at Silver Lake Center during a January 2025 inspection, including residents consistently receiving cold meals, improper infection control practices during a COVID-19 outbreak, and significant kitchen sanitation deficiencies that raised food safety concerns.
Temperature Complaints Lead to Isolation Protocol Investigation
During the inspection, multiple residents reported receiving meals that were cold or inadequately heated, a problem that inspectors traced to the facility's response to an active COVID-19 outbreak affecting 27 residents. The nursing home had implemented a practice of serving meals to COVID-positive residents in disposable foam containers, which staff acknowledged did not retain heat effectively.
One resident recovering from COVID-19 in isolation received breakfast in a foam tray containing fried eggs, toast, and cream of wheat. "My food was served cold," the resident reported to inspectors. The same resident received cold meals at lunch the previous day, stating the chicken, mixed vegetables, and noodles "were not warm but I was going to eat it anyway." At a third meal observation, the resident described lunch as "just not warm enough."
The facility's dietary manager acknowledged that disposable foam trays were used exclusively for COVID-positive residents but stated he was unaware of current Centers for Disease Control guidance indicating that routine food service utensils should be used even during COVID-19 outbreaks, with proper cleaning protocols. The CDC website specifically states that "management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures" during the pandemic.
A second resident, who had worked in the kitchen previously, told inspectors "the food was disgusting" and "the kitchen just don't know how to fix food." This resident reported that lunch arrived cold with uncooked cabbage, leading them to order food from outside the facility. "The food was always cold," the resident stated.
Medical Implications of Temperature Failures
Inadequate food temperatures create multiple health risks for nursing home residents, who often have compromised immune systems and increased nutritional needs. When hot foods fall below 135 degrees Fahrenheit, they enter what food safety experts call the "danger zone" where bacteria can multiply rapidly.
Beyond food safety concerns, chronically cold or unappetizing meals can lead to decreased food intake among elderly residents. This is particularly problematic for individuals with diabetes, wounds requiring healing, or conditions that increase metabolic demands. Reduced caloric intake can result in unintended weight loss, slower wound healing, decreased immune function, and overall decline in health status.
The facility's own policy stated that "food will be prepared by methods that conserve nutritive value, flavor and appearance" and "will be palatable, attractive and served at a safe and appetizing temperature." Resident council minutes from December 2024 documented two complaints about cold food, with the resolution noted as "will follow for trend," indicating the facility was aware of the ongoing problem.
Critical Kitchen Sanitation Deficiencies Documented
Inspectors identified serious cleanliness and food safety violations in the facility's kitchen during multiple visits. Walls throughout the kitchen showed collections of dried food splatters, particularly around the coffee and tea station, cooking range, and handwashing sink. Food debris and dust had accumulated along wall strips and electrical switches, while broken strips along lower walls revealed dark substance buildup where walls met floors. Door frames were damaged, exposing raw wood.
When inspectors asked about the wall conditions, the dietary manager stated that kitchen staff were responsible for walls but claimed housekeeping and maintenance were responsible for tile and floors because they had proper scraping tools, while kitchen staff "only had a mop." When asked for the kitchen's cleaning schedule, the manager stated "it's not posted this week" and was unable to locate a digital copy after searching.
The facility's registered dietitian confirmed identifying "dirty and stained walls" in the most recent monthly sanitation report and acknowledged they "needed thorough cleaning."
Improper Food Cooling Practices Created Contamination Risk
Inspectors observed kitchen staff failing to follow proper cooling procedures for leftover foods on multiple occasions, creating conditions where harmful bacteria could proliferate. According to FDA Food Code requirements, cooked foods must be cooled from 135°F to 70°F within two hours, then to 41°F or below within a total of six hours.
During the first kitchen observation, inspectors found containers of leftover scrambled eggs and sausage that had been removed from the steam table two hours and 45 minutes earlier. When temperatures were checked, pureed scrambled eggs measured 96°F, regular scrambled eggs measured 86°F, and link sausage measured 75°F—all well above the required 70°F maximum for that time period.
The dietary manager acknowledged that ice baths should be used to cool foods quickly but stated this wasn't done "due to short staff." He then placed the improperly cooled containers back into the refrigerator.
Two days later, inspectors observed a similar violation. A 10-inch-deep container of pureed scrambled eggs was placed on ice after breakfast service. Three hours and 45 minutes later, the eggs still measured 93.5°F—far above safe temperatures. Using a deep container rather than shallow pans significantly slowed the cooling process, allowing the food to remain in the danger zone for extended periods.
When questioned about expectations, the registered dietitian stated the kitchen "shouldn't have any leftovers but if they do, they should be in a shallow pan as that's the way to cool it down the fastest."
Missing Temperature Monitoring Equipment
Four cold storage units lacked interior temperature gauges, making it impossible for staff to verify that foods were being stored at safe temperatures. These included a reach-in refrigerator storing produce, two reach-in freezers (one with ice cream, another with vegetables), and a milk storage box. The facility's own sanitation policy required daily inspection of "refrigerators/coolers, freezers, storage area temperatures," which could not be properly completed without functioning thermometers in each unit.
Infection Control Failures During COVID Outbreak
With 27 residents in isolation due to COVID-19, inspectors observed multiple infection control violations that increased the risk of virus transmission. A housekeeper entered a room marked for droplet precautions wearing only an N95 mask and gloves, despite posted signs directing staff to also wear a gown and face shield. The housekeeper exited the room twice while still wearing contaminated gloves, touched the cleaning cart to retrieve supplies, and failed to perform hand hygiene or change protective equipment.
When questioned, the housekeeper acknowledged the posted guidelines should have been followed.
Wound Care Practices Raised Cross-Contamination Concerns
Inspectors observed a registered nurse performing wound care on a COVID-positive resident with a stage 3 pressure ulcer in a manner that created multiple opportunities for cross-contamination. The nurse used a single gauze pad to clean different areas of the wound bed rather than using fresh gauze for each area. When medical-grade honey being applied to the wound dropped onto intact skin below the wound, the nurse used the same applicator to push the honey from the skin into the wound bed.
During the procedure, the nurse's protective gown slipped down, exposing the front of her uniform to the breast area, while the right sleeve fell to elbow level. After completing the wound care, the nurse brought a spray bottle of saline wound cleanser out of the COVID-positive resident's room and placed it in the wound cart without first disinfecting the bottle.
The nurse later acknowledged to inspectors: "I should have fastened the top of my gown before I started the wound care so it wouldn't slide down. I should have also cleaned the bottle of saline wound cleanser with a disinfectant wipe before putting it in the bottom of the wound cart."
The Director of Nursing stated expectations were that nurses should "clean the wound bed using a circular motion with one 4x4 then discard it and then get a clean 4x4 to clean the wound bed again" and that because the resident was COVID-positive, "nothing should have been brought out of his room that the nurse took into the room for wound care."
Antibiotic Stewardship Program Inadequately Implemented
Inspectors found the facility's antibiotic stewardship program lacked consistent implementation and documentation. The facility maintained a monthly infection surveillance log, but review of records from September 2024 through January 2025 revealed a pattern of missing critical data.
Of 22 infection entries in January 2025, 12 residents were treated with antibiotics, but documentation frequently omitted whether clinical criteria for infection diagnosis were met, which specific antibiotics were administered, and results of culture and sensitivity testing to confirm the chosen antibiotic would be effective against the identified organism.
The facility's policy required monitoring antibiotic response, reviewing appropriateness of prescriptions, conducting random audits, and tracking outcome measures monthly. However, there was no documented evidence that staff analyzed data from infection logs to identify trends, patterns, or potential areas for improvement.
The infection preventionist, who was new to the role, confirmed the missing data when questioned by inspectors. Neither the infection preventionist nor the Director of Nursing maintained floor plans showing infection locations to identify potential clusters or transmission patterns.
Proper antibiotic stewardship is essential in nursing homes, where overuse and inappropriate prescribing contribute to antibiotic-resistant infections. Elderly residents are particularly vulnerable to complications from resistant organisms, including increased mortality rates and longer hospital stays.
Additional Issues Identified
Food Service Equipment: A thermometer used to check food temperatures could not be calibrated, raising questions about the accuracy of temperature readings. When oatmeal was tested and registered at 135°F, inspectors noted it tasted only lukewarm.
Infection Data Analysis: December 2024 records showed 18.8% of residents had infections, but the facility provided no evidence of using this data to identify improvement opportunities or implement preventive measures.
Staff Training Gaps: Multiple instances suggested insufficient staff training on infection control protocols, proper food handling procedures, and kitchen sanitation standards.
The inspection findings indicate systemic issues affecting food service, infection prevention, and quality oversight at the facility. Federal regulations require nursing homes to maintain comprehensive infection control programs and serve palatable, properly temperatured food to protect resident health and quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Silver Lake Center from 2025-01-23 including all violations, facility responses, and corrective action plans.
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