Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Newark Manor Nursing Home during CMS and state inspections, most recent first.
Two residents with severe cognitive and physical impairments were not adequately supervised, resulting in one sustaining a fracture from contact with a bed enabler and another suffering a head laceration and sacral fracture after being left unsupervised in a bathroom. The facility failed to identify accident hazards, implement person-centered fall interventions, and provide timely emergency response, with staff misrepresenting incident details and care plans lacking clear supervision instructions.
A resident with increased pain and decreased movement in the left arm had a STAT x-ray ordered and completed, but the results were delayed for about 48 hours. During this time, an RN learned of the delay from the x-ray company but did not notify the on-call provider. The provider was only notified after the resident's POA insisted on sending the resident to the ER. There was no documentation that the provider was informed of the delay as required.
A resident with dementia and vision loss was left unattended in a bathroom by a CNA, resulting in a fall and head injury. The CNA misrepresented the location of the fall, and the facility did not thoroughly investigate the incident or clarify the circumstances until nearly two weeks later. Documentation and staff interviews revealed gaps in assessment and reporting, with the true details only emerging during a later care conference.
A resident with dementia, legal blindness, and a pacemaker did not have a person-centered care plan addressing all aspects of pacemaker management. The care plan lacked details such as device type, settings, battery status, education for the resident/family, and monitoring of the pacemaker site, as confirmed by staff interviews and record review.
The facility did not ensure that bed rail care plans for three residents were person-centered or included necessary monitoring, ongoing assessment, risk evaluation, or identification of responsible staff for discontinuation. In one case, a resident was observed with both bed rails up despite a care plan for only one. These deficiencies were confirmed through record review, observation, and interviews with the DON.
Surveyors found that the facility did not ensure proper assessment, monitoring, or maintenance of bed rails for several residents. In multiple cases, residents were fully dependent on staff for mobility and unable to use bed rails as intended, yet the rails remained in use without documented reassessment. Additionally, there was no evidence of required preventive maintenance or safety checks for the bed rails, as confirmed by staff interviews.
A resident experiencing increased pain and decreased movement of the left arm had a STAT x-ray ordered, but the facility did not receive the results, which showed an acute nondisplaced fracture, until about 48 hours later due to limited weekend staff coverage by the x-ray provider. STAT x-ray results are typically completed within two hours, but this delay failed to meet the resident's acute medical needs.
A resident with dementia and severe cognitive impairment suffered a broken nose and facial lacerations after being physically assaulted by a roommate with a history of aggressive behavior. Despite care plans and safety checks in place, the incident occurred when staff were not present to intervene, and prior behavioral history from another facility was not fully communicated before admission.
A resident did not receive multiple doses of prescribed medications for depression and an enlarged prostate due to delays in pharmacy delivery and insurance-related issues. Facility staff documented repeated unavailability of the medications and confirmed that confusion over pharmacy responsibilities and prescription requirements led to the missed doses. The attending physician was not promptly notified of the delays.
The facility failed to provide written transfer notices to residents, their responsible parties, and the LTC Ombudsman when residents were transferred to the hospital. This deficiency was identified for two residents, and interviews with staff confirmed that the facility's policy did not address the need for written notifications. The Director of Nursing was unaware of the requirement for written notifications, and the Ombudsman confirmed not receiving any notifications over the past year.
The facility did not provide written bed hold notices to two residents or their families during hospital transfers, as required by policy. Interviews confirmed that while the policy was communicated upon admission, it was not reiterated during transfers. The DON noted a discrepancy in the bed hold duration used by the facility.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and were protected from accident hazards, resulting in harm. One resident, who was dependent, cognitively impaired, and legally blind, sustained a left upper extremity fracture after accidental contact with a bed enabler during care. The facility did not identify the left bed rail as a potential hazard, despite the resident's significant physical and cognitive limitations. Documentation showed that the resident was dependent for all activities of daily living, required a Hoyer lift for transfers, and had a history of pain complaints, but there was no evidence that the risk posed by the bed enabler was adequately assessed or mitigated. Another resident, also severely cognitively impaired and dependent for all activities of daily living, experienced multiple falls over several months, including unwitnessed falls in various locations. The resident's care plan identified a high risk for falls but lacked person-centered interventions tailored to her needs. On one occasion, the resident was left unsupervised in a bathroom by a CNA who left to obtain an incontinent brief, resulting in a fall that caused a scalp laceration and a subtle sacral fracture. The CNA misrepresented the location and details of the incident, and the facility did not thoroughly investigate the true circumstances of the fall until 12 days later. Additionally, after the unwitnessed fall with a head injury, the facility failed to implement timely emergency interventions. The resident was not assessed by a registered nurse at the scene before being moved, and there was a delay of nearly three hours before the resident was sent to the emergency room. Interviews with staff revealed gaps in communication and documentation, as well as a lack of clear instructions for staff regarding supervision requirements for high-risk residents. The facility's documentation and care plans did not provide adequate guidance to prevent such incidents, despite the residents' extensive histories of falls and cognitive impairment.
Failure to Notify Provider of Delayed STAT X-ray Results
Penalty
Summary
A deficiency occurred when the facility failed to notify the on-call provider regarding delayed STAT x-ray results for a resident who was experiencing increased pain and decreased movement in the left arm. A STAT elbow x-ray was ordered and completed, but the results were not received for approximately 48 hours. During this period, a registered nurse contacted the mobile x-ray company and learned of the delay but did not inform the on-call provider about the missing results. The lack of timely notification to the provider persisted until the resident's power of attorney became upset and requested that the resident be sent to the emergency room, at which point the provider was finally notified and an order was obtained to send the resident out for further evaluation. The clinical record review and staff interview confirmed that there was no evidence of provider notification about the delay in receiving the STAT x-ray results, which was required by facility policy and regulations.
Failure to Investigate and Accurately Report Resident Fall
Penalty
Summary
A resident with dementia, permanent vision loss, and difficulty walking was admitted to the facility and had a care plan noting poor safety awareness and impulse control. On the day of the incident, the resident was left unattended in a bathroom by a CNA who left to obtain an incontinent brief. During this time, the resident fell and sustained a superficial laceration to the back of the head. The CNA returned, found the resident on the floor, placed the resident in a wheelchair, and misrepresented the location of the fall to the supervisor, stating it occurred in the dining room. The facility did not thoroughly investigate the true circumstances and location of the fall until 12 days after the event, despite conflicting reports and documentation. The LPN who documented the incident did not assess the resident post-fall, as she was on break and relied on information from the RN supervisor. The actual details of the incident were only clarified during a multidisciplinary care conference, revealing the CNA's misrepresentation and the resident being left unattended. The findings were confirmed with the DON and reviewed during the exit conference with facility leadership.
Failure to Develop Person-Centered Pacemaker Care Plan
Penalty
Summary
A deficiency was identified when a resident with dementia, legal blindness, and sick sinus syndrome was admitted to the facility with a pacemaker. The clinical record documented the presence of the pacemaker and included a care plan with general goals and interventions, such as monitoring vital signs and reporting symptoms of pacemaker malfunction. However, the care plan did not include specific, person-centered details related to the resident's pacemaker. The care plan lacked essential information such as the pacemaker's type, settings, programmed rate, and battery status. Additionally, there was no documentation of education provided to the resident or family regarding the pacemaker's purpose, function, potential complications, or the importance of follow-up with a cardiologist. The plan also omitted monitoring of skin integrity at the pacemaker site. These omissions were confirmed during interviews with facility staff and during the exit conference.
Failure to Maintain Person-Centered Bed Rail Care Plans and Monitoring
Penalty
Summary
The facility failed to ensure that bed rail care plans for three residents were adequately reviewed and revised to be person-centered and to meet their medical needs. For each of these residents, the care plans included interventions such as documenting the use of bed rails as enablers, ensuring valid consent, and obtaining physician orders. However, the care plans lacked documentation of monitoring and supervision during bed rail use, ongoing assessment to confirm the bed rail continued to meet the resident's needs, evaluation of risks, identification of the person responsible for discontinuing the bed rail, and interventions to address any adverse effects from bed rail use. Observations and record reviews revealed that, despite care plans specifying the use of a single bed rail as an enabler, one resident was observed with bilateral bed rails in the up position. Interviews with the DON confirmed these findings. The deficiencies were discussed with facility leadership during the survey process, and the lack of comprehensive, individualized care planning and monitoring for bed rail use was consistently identified across the reviewed cases.
Failure to Ensure Appropriate Use and Monitoring of Bed Rails
Penalty
Summary
Surveyors identified that the facility failed to ensure appropriate use and ongoing monitoring of bed rails for three out of seven residents reviewed. The facility's policy required assessment by physical therapy, physician orders, informed consent, proper installation, care plan updates, and reassessment every six months. However, documentation and observations revealed that these steps were not consistently followed. For example, one resident had a left bed enabler for assistance with positioning, but subsequent assessments showed the resident was fully dependent on staff for all activities of daily living (ADLs) and required a Hoyer lift, with no evidence that the continued use of the bed rail was reviewed for appropriateness. Another resident had a right side bed enabler ordered for assistance with turning and repositioning, but was documented as dependent for bed mobility and required two staff for rolling in bed. During care, the resident was unable to use the bed rail due to a contracted hand, and staff confirmed the resident's dependence for turning. A third resident had a physician's order for a single bed rail, but was observed with bilateral bed rails in use. This resident also required two staff for turning and repositioning, and was unable to use one of the bed rails as intended during care. Additionally, the facility lacked evidence of preventive maintenance or safety checks for the bed rails in use. Staff confirmed that there was no documentation of such checks, despite the manufacturer's guidelines being available. These findings indicate that the facility did not ensure bed rails were used according to policy and did not maintain ongoing safety monitoring for residents using bed rails.
Delay in STAT X-ray Results for Acute Medical Need
Penalty
Summary
The facility failed to meet the acute medical needs of a resident by not obtaining timely STAT x-ray results following a physician's order for an elbow x-ray due to increased pain and decreased movement of the left arm. The order was placed on 7/18/25, but the x-ray results, which revealed an acute nondisplaced fracture of the left humeral neck, were not received and faxed to the facility until approximately 48 hours later. According to a representative from the x-ray company, STAT x-ray results are typically completed within two hours on the same day, but limited staff coverage over the weekend delayed the reading and notification to the facility.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A resident with severe cognitive impairment and dementia (R462) was physically abused by their roommate (R461), resulting in a broken nose and laceration to the bridge of the nose. R462 had no prior behavioral symptoms, while R461 had a history of depression, insomnia, adult personality and behavior disorder, and was care planned for impaired thought process and aggressive behaviors. R461's care plan included multiple interventions to address physical and verbal aggression, particularly during night shift hours, and required frequent safety checks. Despite these interventions, an incident occurred late at night when staff were called to the room and found R462 actively bleeding from the face after being struck by R461. Both residents were separated and sent to the emergency department for evaluation, where R462 was diagnosed with a nasal fracture and facial lacerations. Documentation indicated that R461 had accused R462 of stealing, which precipitated the physical altercation. The facility's records also revealed that some information about R461's aggressive behaviors from a previous facility was not communicated prior to admission. Family members reported that they were told the facility would provide close monitoring of R461, especially when he was up and near his roommate, but it appeared that no one was present to supervise at the time of the incident. The facility failed to ensure that R462 was protected from physical abuse by R461, resulting in significant harm.
Failure to Administer Physician-Ordered Medications Due to Pharmacy and Insurance Delays
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received prescribed medications according to physician orders. The resident had active orders for tamsulosin HCL for an enlarged prostate, and aripiprazole and escitalopram oxalate for depression. Review of the Medication Administration Record for May 2024 revealed multiple missed doses of these medications over several days. Nurse progress notes repeatedly documented that the medications were unavailable and that the facility was awaiting delivery from the pharmacy. Interviews with facility staff confirmed that the missed doses were due to delays in obtaining the medications, which stemmed from insurance issues and confusion regarding which pharmacy was responsible for filling the prescriptions. The facility pharmacy provider was unable to fill the medications due to insurance restrictions, and the alternate pharmacy required prescriptions from a specific physician, causing further delays. The attending physician was not notified of the ongoing delays until several days after the missed doses began.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices to residents and their responsible parties, as well as to the Long Term Care Ombudsman, when residents were transferred to the hospital. This deficiency was identified for two residents out of a sample of 26. The facility's policy on discharge to a hospital or another LTC facility did not include the requirement for written notices, which led to the oversight. Specifically, Resident 54 was transferred to the hospital without any documented evidence of written notification to the responsible party or the Ombudsman. Similarly, Resident 312 was sent to the hospital for further evaluation and treatment without a written transfer notice being provided to the resident, their family, or the Ombudsman. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that the facility's policy did not address the need for written notifications of transfers. The Director of Nursing admitted to notifying responsible parties by telephone but was unaware of the requirement for written notifications to both the responsible parties and the Ombudsman. The Long Term Care Ombudsman also confirmed not receiving any notifications of resident transfers from the facility over the past year.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written information regarding its bed hold policy to residents and their responsible parties at the time of transfer to a hospital or within 24 hours of the transfer. This deficiency was identified for two residents, R54 and R312, out of a sample of 26 residents reviewed for hospitalizations. The facility's policy, as outlined in the admission package, states that for Medicaid residents, the bed will be held for up to seven days, and for private pay residents, a fee of $150 per day applies. However, there was no evidence in the electronic medical records or thinned charts that bed hold notices were given to R54 and R312 or their families upon their transfers to the hospital. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that bed hold notices were not provided at the time of transfer or within 24 hours. The Director of Nursing acknowledged that while residents and their responsible parties were informed of the bed hold policy upon admission, this information was not reiterated during hospital transfers. Additionally, the Director of Nursing mentioned that the facility was using a 30-day bed hold policy instead of the seven days stated in the policy. The Long-Term Care Ombudsman also expressed concerns about not receiving bed hold notices for the past year.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Newark
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Encore At Parkside | 2.2 mi | ★★★★★ | 27 | 1 |
| Exceptional Care For Children | 2.3 mi | ★★★★★ | 0 | 0 |
| Jeanne Jugan Residence | 3.8 mi | ★★★★★ | 4 | 0 |
| Pike Creek Nursing & Rehabilitation Center | 5.4 mi | ★★★★★ | 6 | 0 |
| Excelcare At Newark Llc | 5.4 mi | ★★★★★ | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.