Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Newport House during CMS and state inspections, most recent first.
Food items in the kitchen were found unlabeled, undated, and/or unsealed in the reach-in freezer, walk-in refrigerator, and walk-in freezer. Surveyors observed multiple bags of food, open sliced cheese, and a sheet pan item that were not properly labeled or sealed, and the Sous Chef and TLFNS confirmed the items should have been labeled or sealed.
Multiple infection control failures were observed during resident care and equipment handling. Staff used a Hoyer lift for transfers without disinfecting it, did EBP cares for a resident with an ileostomy and PEG tube without wearing gowns, left a nebulizer kit with residual liquid after use, failed to perform hand hygiene between glove changes during perineal care, and handled washcloths in ways that could cause cross contamination. Respiratory equipment for another resident was also left undated or stored improperly, including nebulizer tubing, an O2 humidification bottle, BiPAP tubing on the floor, and a BiPAP mask on a bedside table without a barrier.
A resident with a history of stroke, hemiplegia, moderate cognitive impairment, and chronic constipation repeatedly refused multiple ordered bowel medications over an extended period, as documented on the MAR and in nursing progress notes. RNs educated the resident several times about the importance of the bowel regimen while noting prolonged absence of BM and episodes of vomiting, but the refusals continued. Facility policy required notifying the physician when treatment needed to be significantly altered, using an SBAR tool for communication. Record review showed no evidence that the provider was notified of the ongoing medication refusals, and there were no documented parameters for notification in the orders or care plan; the RN team lead and DON confirmed that no SBAR or other provider notification was found.
A resident with CHF, delirium, depression, anxiety, and hospice services had PRN Lorazepam continued beyond the 14-day limit without a clear documented rationale on the pharmacist recommendation. The MAR and progress notes showed PRN doses were given for anxiety, but no behaviors or non-pharmacological interventions were documented, and the DON confirmed the rationale was anxiety.
Failure to implement a comprehensive nutrition care plan. A resident with severe cognitive impairment, extensive assistance needs, and about 50% meal intake had a baseline plan for a mechanical soft diet and eating assistance, but the comprehensive care plan did not include altered nutrition. The RD confirmed the nutrition care plan should have been in place earlier but was not implemented until later.
A resident with severe cognitive impairment and extensive feeding assistance needs experienced significant weight loss after poor PO intake, decreased fluids, and swallowing difficulty were documented. The hospital dietary consult recommended a soft diet and Ensure with meals, but no supplement orders were entered and no nutrition care plan was in place. Weights showed a loss of more than 6% within 30 days, and the RD confirmed the weight loss was not identified until later and interventions were not put into place until after the significant loss was noted.
Medication Administration Errors Exceeded Allowed Rate: The facility had an 8% med error rate, with 2 errors out of 25 opportunities. An RN gave riluzole to one resident while the resident was eating, even though the order required it to be given by PEG tube 1 hour before or 2 hours after meals, and another RN gave omeprazole to a second resident with breakfast instead of 60 minutes before the meal.
The facility failed to properly dispose of medications as observed during medication administration. An RN and an LPN were seen disposing of dropped medications in the trash can attached to the medication cart, contrary to facility policy. Both staff members confirmed their lack of knowledge regarding proper disposal procedures, as verified by the DON.
Food Storage Items Left Unlabeled and Unsealed
Penalty
Summary
Food stored in the kitchen was not labeled, dated, and/or sealed in accordance with the facility’s Food Storage General Guidelines policy and the FDA Food Code 2022. During observation of the large reach-in freezer, surveyors found multiple items that were not labeled or sealed, including a clear bag of small round brown substance, a clear bag of large flat tan/brown substance, two brown bags of yellow elongated substance identified by staff as French fries, and a brown bag of tan round substance identified by staff as tator tots. In the walk-in refrigerator, an open package of sliced cheese was observed that was not sealed. In the walk-in freezer, surveyors observed a large sheet pan with round, colorful, tan substance that was not labeled, dated, or sealed. During interview, the Sous Chef confirmed the unlabeled and unsealed items in the freezer should have been labeled or sealed, and identified the brown bag of yellow elongated substance as French fries and the brown bag of tan round substance as tator tots. The Team Lead Food Nutrition Services also confirmed the open sliced cheese in the walk-in refrigerator and the unlabeled, undated, and unsealed sheet pan item in the walk-in freezer should have been sealed and labeled.
Infection Control Failures During Resident Care and Equipment Handling
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed during multiple resident care activities and equipment handling. The report states that Hoyer lifts were used for transfers without being disinfected before or after use. On one occasion, staff brought the lift into Resident 7’s room without disinfecting it, used it to transfer the resident from a wheelchair to bed, and then placed it back in the hallway without cleaning it. The same lift was later taken into another resident’s room and used again without disinfection. An RN and NA confirmed the lift had not been disinfected before or after use, and the DON confirmed staff should have disinfected it. The facility also failed to follow barrier precautions and hand hygiene expectations during care for a resident in EBP. Resident 14 had an ileostomy and PEG tube and was identified in the care plan as requiring gowns and gloves during high-contact care. During PEG tube care, an RN performed hand hygiene and gloved but did not wear a gown. During ileostomy care, an NA performed the task with gloves but without a gown. The RN confirmed the resident was in EBP and that both staff members should have worn gowns during those cares. Additional infection control failures involved respiratory equipment and linen handling. Resident 7’s nebulizer administration kit was observed multiple times with residual liquid remaining in it, and staff did not rinse the kit after use as required by facility policy. During incontinence and hygiene care for Resident 3, an NA removed soiled briefs, performed perineal care, removed gloves, and reapplied new gloves without hand hygiene. The same NA also placed washcloths on the bedside table without a barrier and squeezed washcloths against the sink basin before using them for facial and perineal care; both the NA and RN confirmed these actions could cause cross contamination. For Resident 9, respiratory equipment was observed stored and maintained without required labeling or proper placement. The resident had orders for oxygen, BiPAP with heated humidification, and nebulizer treatment. The nebulizer kit and tubing were undated, the disposable oxygen humidification bottle was undated, the BiPAP bleed-in tubing was stored on the floor, and the BiPAP mask was left on the bedside table without a barrier. The LPN and the ADON/Infection Preventionist confirmed these items should have been dated and stored in a manner to prevent cross-contamination.
Failure to Notify Provider of Ongoing Refusal of Bowel Regimen
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the medical practitioner of ongoing refusals of prescribed bowel medications for one resident. The facility’s policy, last reviewed on 08/27/2018, required notification of the physician or designee and the resident’s legal representative when there was a need to significantly alter treatment, including discontinuation of existing treatment due to ineffectiveness or adverse consequences, or initiation of new treatment. The policy specified use of an SBAR tool for non-emergent notifications, with documentation to be filed in the physician’s order section of the chart. Despite this policy, the facility did not notify the provider when the resident repeatedly refused bowel regimen medications over a series of days. The resident involved had a history of cerebral infarction with right-sided hemiplegia/hemiparesis, difficulty walking, moderate cognitive impairment (BIMS score of 7), and constipation. The comprehensive care plan included monitoring for constipation, monitoring bowel and bladder patterns every shift, and ongoing education about bowel management, noting that the resident often stated it was normal to go a lengthy time between bowel movements and that the resident sometimes refused bowel protocol due to past work circumstances. Physician orders included multiple bowel regimen medications (prune products PRN, milk of magnesia PRN, senna, bisacodyl suppository PRN, Motegrity, Miralax, and an order to document bowel sounds and abdominal characteristics daily). Medication Administration Records showed that over a 10-day period the resident refused docusate sodium 15 of 20 scheduled doses, refused Motegrity and Miralax 8 of 10 scheduled doses, and refused senna on 2 occasions. Progress notes documented repeated refusals despite RN education on the importance of bowel medications and more frequent bowel movements, and noted the resident had gone 7 and then 8 days without a bowel movement while continuing to refuse bowel protocol, though bowel sounds were active in all quadrants at those times and the resident denied pain or discomfort. Additional notes documented vomiting episodes and changes in bowel sounds on one day. A physician dictation later acknowledged the resident had not been taking the bowel regimen because of dislike of the medications. However, review of progress notes, scanned documents, and the physical chart revealed no evidence that the medical practitioner had been notified of the repeated refusals, and there were no documented parameters for notification of medication refusals in the physician’s orders or care plan. The RN Team Lead and DON confirmed there was no evidence of SBAR communication or provider notification for these refusals during the period reviewed.
Missing documented rationale for continued PRN Lorazepam
Penalty
Summary
The facility failed to ensure a rational was documented to continue PRN Lorazepam beyond 14 days for one resident. Resident 7 had diagnoses of chronic diastolic CHF, delirium due to a known physiological condition, depression, and anxiety, and was noted on the MDS to have a BIMS score of 15, indicating cognitive awareness. The resident required varying levels of assistance with activities of daily living, had no behaviors, and was receiving hospice services. Resident 7 had standing orders for scheduled Lorazepam at bedtime and PRN Lorazepam concentrate every hour as needed for anxiety. The PRN Lorazepam was administered twice in January 2026, and the progress notes for those administrations documented anxiety but did not document behaviors or non-pharmacological interventions. A pharmacist recommendation dated 10/08/2025 noted CMS required a 14-day stop on PRN psychotropic medications unless the prescriber documented clinical rational for continued use and a new duration; the prescriber agreed to continue the medication for 6 months, but the response did not include a clear rational for continued PRN use. The DON confirmed that the rational documented for the continued PRN Lorazepam was anxiety and that, for a normal resident not on hospice, a rational should have been documented on the pharmacist recommendation.
Failure to Implement Comprehensive Nutrition Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan to prevent the potential for altered nutrition for Resident 3. The resident’s MDS dated 01-04-2026 showed admission to the facility, an admission weight of 173 lbs, a BIMS score of 0 indicating severe cognitive impairment, extensive assistance needed with eating, and total assistance needed with hygiene, dressing, bed mobility, transfers, toileting, and bathing. The baseline care plan dated 12-31-2025 noted a regular mechanical soft diet and assistance with eating. The Nutrition Assessment dated 01-04-2026 identified a goal to provide adequate nutrition and hydration and improve oral intake to 75% or greater at 2 meals daily, and documented that the resident had no edema, was averaging 50% meal intake, would be followed for possible oral nutritional supplements, and had no skin breakdown. The comprehensive care plan dated 01-05-2026 did not include a plan of care for altered nutrition, and the Registered Dietician confirmed on 01-28-2026 that a comprehensive care plan for altered nutrition should have been implemented on or before 01-20-2026 but was not implemented until 01-26-2026.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to evaluate, monitor, and implement interventions for Resident 3’s significant weight loss. Resident 3 was admitted with a weight of 173 pounds, had severe cognitive impairment with a BIMS score of 0, and required extensive to total assistance with eating and most activities of daily living. The hospital dietary consult noted poor oral intake, trouble with a regular diet, and family assistance with eating, and recommended a soft diet and Ensure three times daily. However, the resident’s order summary and MAR showed no orders for Ensure or other nutritional supplements, and the comprehensive care plan had no nutrition care plan. Resident 3’s weights showed a decline from 172.2 pounds to 166.0 pounds, then to 162.0 pounds, which was a 6.15% loss within 30 days and a significant weight loss, and later to 161.3 pounds, a 6.32% loss within 30 days of admission. The nutrition assessment documented average meal intake of 50% and noted the resident would be followed for possible oral nutritional supplements, but the record contained no evaluation or implementation of interventions when the significant weight loss was identified. Progress notes also documented decreased fluid intake, change in appetite, difficulty swallowing at times, and new orders to encourage fluids and monitor for decreased appetite, weight loss, and worsening kidney function. During observation, the resident ate only a few bites of breakfast while the daughter assisted.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with 2 medication errors identified out of 25 opportunities for error, resulting in an 8 percent medication error rate. The facility policy required medications and treatments to be stored and administered in a safe and effective manner and to follow the 6 rights of medication administration, including the right time and right documentation. During observation, RN E administered multiple medications to Resident 84 while the resident was eating breakfast, including riluzole 50 mg. The resident’s order required riluzole 50 mg to be given by PEG tube twice daily, 1 hour before or 2 hours after a meal, and RN E confirmed it was not given within that time frame. In a separate observation, RN D administered omeprazole 20 mg to Resident 52 while the resident was eating breakfast. The resident’s order required omeprazole 20 mg daily to be given 60 minutes before meals, and RN confirmed it was given with breakfast instead of before the meal.
Improper Medication Disposal by Nursing Staff
Penalty
Summary
The facility failed to dispose of medications in accordance with standard practice, as observed during a medication administration process. During an observation, a Registered Nurse (RN) dropped a Tylenol 500 mg tablet on the floor and subsequently disposed of it in the trash can attached to the medication cart. The RN confirmed in an interview that they were unaware of the proper procedure for disposing of medications. Similarly, a Licensed Practical Nurse (LPN) was observed placing several medications, including Atorvastatin, Sertraline, Amlodipine, Memantine, Aspirin, Carvedilol, and Donepezil, into a medication cup. While preparing to crush these medications, they fell on the floor. The LPN picked up the medications and disposed of them in the trash can attached to the medication cart. The LPN also confirmed in an interview that they did not know the correct disposal procedure. The Director of Nursing (DON) confirmed that both the RN and LPN did not follow the facility's policy for medication disposal.
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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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| Brookestone Village | 1 mi | ★★★★★ | 10 | 0 |
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| Hillcrest Millard Llc | 2.2 mi | ★★★★★ | 10 | 0 |
| The Banyan At Montclair | 2.4 mi | — | 19 | 0 |
| The Lighthouse At Lakeside Village | 2.5 mi | ★★★★★ | 2 | 0 |
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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.