Average — CMS composite of the measures below.
A standard survey is most likely before 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 Meadows Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and chronic pain had PRN Oxycodone orders that were adjusted around a surgical procedure, but the facility failed to maintain complete and accurate MAR documentation. On numerous occasions, doses of Oxycodone recorded on the controlled substance administration record were either missing from the EMR MAR or documented at different times than shown on the controlled substance record. Facility policy required full documentation of pain assessments, medication, dose, route, and results in the medical record, yet the DON acknowledged that EMR entries did not match the controlled substance record, resulting in incomplete clinical records.
A resident who was frequently incontinent and dependent on staff for toileting was found with a soaked incontinence brief late in the morning, indicating that timely incontinent care had not been provided. Documentation showed the last care was recorded during the night shift, and staff interviews confirmed that morning care was delayed due to competing duties. The DON verified that care was not provided as needed, in violation of facility policy.
Medication Storage and Labeling Deficiency: The facility failed to properly label and store medications in three medication carts. Surveyors found an open vial of Lispro insulin past its expiration, an open undated container of Dorzolamide eye drops, another Lispro insulin vial with no expiration date after opening, and an open container of Latanoprost eye drops with no open or expiration date. Facility policy and manufacturer directions required opened medications to be dated and discarded within the specified timeframes.
A resident with CHF, ESRD, and DM had an active 1500 ml fluid restriction order, but staff documented only yes/no compliance on the MAR instead of the actual amount consumed. Facility policy required documentation of whether the restriction was accepted or not accepted, and the RD stated she could not accurately assess the resident’s true fluid intake from the records. The DON and ADON confirmed the findings.
Failure to Notify Resident Before Room Change: A resident with major depressive disorder, DM, and bladder cancer was sent to the hospital for abdominal pain, and while away the facility changed the resident’s room without prior notice. When the resident returned by stretcher with two attendants, the resident became upset, refused the new room, and was taken back to the hospital. The resident later confirmed no notification was given, and the NHA verified the room change occurred while the resident was hospitalized.
The facility failed to keep privacy curtains clean when they were visibly soiled on the Dogwood unit. Surveyors observed stained curtains in multiple resident rooms, with brown and/or red substances noted on curtains in several rooms. The NHA said she would investigate, and the DON stated housekeeping usually cleans privacy curtains when a resident is discharged or when notified they are visibly soiled.
Failure to provide SNF ABN when Medicare coverage ended. The facility did not provide the required SNF ABN to two residents or their representatives when Medicare Part A services ended. Records showed the forms were reportedly mailed to family members but never returned, and there was no further documentation that the residents or representatives were informed of possible non-coverage or financial liability.
A resident with multiple medical conditions experienced increased slurred speech, which was observed by an LPN but not reported to the physician or documented, contrary to facility policy. Family concerns later prompted assessment and hospital transfer, where the resident was diagnosed with Dilantin toxicity. The facility failed to ensure timely physician notification of the resident's change in condition.
The facility did not meet the required nurse aide staffing ratios during specific shifts over a period, failing to provide one nurse aide per 10 residents during the day on four days, one per 11 residents during the evening on one day, and one per 15 residents during the night on one day. These deficiencies were identified through staffing data review and communicated to the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per day on seven occasions, with PPDs ranging from 2.83 to 3.19. This was identified through staffing data review and communicated to the Nursing Home Administrator.
The facility failed to maintain required nurse aide staffing ratios over several shifts in December 2024, with deficiencies confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient day for nine days, with PPD ranging from 2.76 to 3.09. This deficiency was identified through staffing data review and communicated to the Nursing Home Administrator.
A resident in an LTC facility was mistakenly given their roommate's medications by an LPN, who failed to properly verify the resident's identity. This error led to the resident experiencing bradycardia and hypotension, requiring emergency medical treatment and hospitalization. The incident was identified as past non-compliance due to the LPN not following the facility's medication administration policy.
A resident suffered second-degree burns after a nursing employee failed to ensure a reheated beverage was at a safe temperature before serving. The resident, who was cognitively intact, requested their coffee to be reheated, but the facility did not document temperature checks as required by policy, leading to the injury.
The facility failed to monitor and assess side effects of antipsychotic medications for three residents. Two residents on Abilify lacked side effect monitoring in their MARs, while another resident on Risperidone had improper documentation of side effect monitoring. These issues were confirmed with the DON.
The facility failed to follow COVID-19 infection control measures on the 1st Floor Chestnut Unit. An employee did not change PPE or perform hand hygiene between resident tests, and the facility did not notify visitors of COVID-19 presence. The DON confirmed the need for proper PPE use and visitor screening.
The facility failed to develop and implement comprehensive care plans for two residents. One resident receiving oxygen therapy lacked a care plan for this intervention, while another with a wrist contracture had no care plan addressing the condition or the recommended intervention of using a rolled-up washcloth. These deficiencies were confirmed by the DON, indicating a lack of proper documentation and planning for the residents' needs.
A facility failed to follow physician orders for a resident's fluid restriction, with records showing the resident consistently consumed more fluids than prescribed. The nursing staff did not document fluid intake, and the DON confirmed the dietary fluid restriction was not followed.
A deficiency was found in the pharmacy services when a physician disagreed with a Consultant Pharmacist's recommendation for a GDR for a resident but failed to provide a clinical rationale. This was confirmed by the DON, indicating non-compliance with regulatory requirements.
A resident experienced a delay in receiving an x-ray for a foot injury after a fall, as recommended by a podiatrist. The x-ray, which was ordered on the day of the podiatry consult, was not performed until several days later, revealing a fracture. This delay was confirmed by the DON.
A facility failed to accurately follow physician medication orders for a resident with Epilepsy and IBS. Prednisone was incorrectly transcribed in the MAR, leading to improper administration. Additionally, Mesalamine was not administered due to unavailability, and the physician was not consistently notified of the missed doses.
The facility failed to implement Enhanced Barrier Precautions for three residents with wounds, as required by their policy. Observations showed no signage or PPE at the room entrances, and a nurse confirmed that staff had to request PPE from housekeeping. This deficiency was noted during a review of the facility's infection control practices.
The facility failed to obtain physician's orders for immediate care at the time of admission for a resident requiring dialysis. Despite documentation indicating the need for dialysis three times a week, the physician's admission orders did not include these instructions. This was confirmed through an interview with the NHA and Assistant NHA.
Incomplete and Inaccurate Documentation of Controlled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medication administration records for a cognitively intact resident with multiple chronic conditions, including bladder cancer, diabetes mellitus, depression, chronic pain syndrome, and a right below-knee amputation. Facility policy on administering pain medications requires documentation of the pain assessment, medication, dose, route, and results of the medication in the resident’s medical record. The resident had an order for Oxycodone HCL 15 mg by mouth every 8 hours as needed for moderate to severe chronic pain, later changed to every 6 hours for a post-surgical period and then changed back to every 8 hours. Review of the February and early March 2026 MARs and the Individual Patient Controlled Substance Administration Record showed multiple discrepancies between doses documented on the controlled substance record and those recorded in the electronic medical record (EMR). On multiple dates in February and March 2026, doses of Oxycodone were recorded as administered on the Patient Controlled Substance Administration Record but were either missing or documented at different times in the EMR. Specifically, on several dates in February, one or more doses given at documented times (e.g., midnight, morning, afternoon, or late evening) on the controlled substance record were not recorded at all on the EMR MAR. On other dates, the times of administration differed between the two records, such as doses documented at 8:00 AM and 2:00 PM on the controlled substance record but at 9:11 AM and 3:00 PM in the EMR. Additional missing EMR entries occurred after the order reverted to every 8 hours, with several doses documented on the controlled substance record not appearing in the EMR. During an interview, the DON acknowledged that the EMR documentation was incomplete and did not reflect the controlled substance administration record, indicating noncompliance with the requirement to maintain clinical records in accordance with accepted professional standards.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident who was frequently incontinent of bladder and dependent on staff for toileting. According to the resident's Minimum Data Set (MDS), the resident required assistance with toileting and was frequently incontinent. On the morning of the observation, the resident was found in bed with a soaked incontinence brief containing dark yellow/light brown urine, and their hair was disheveled. The staff member assigned as the resident's morning aide confirmed that incontinent care had not been provided since the aide's arrival at 7:00 a.m., as other duties such as passing breakfast trays and preparing residents for the hair salon took precedence. The aide was unsure when the night shift last provided care. A review of the resident's care documentation indicated that the last recorded incontinent episode was at 1:08 a.m., with toileting hygiene marked as not applicable at that time. The Director of Nursing confirmed that the resident did not receive timely incontinent care. The facility's policy requires staff to appropriately manage urinary incontinence and provide services to prevent urinary tract infections, but these procedures were not followed for this resident.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure appropriate storage and labeling of medications in three of four medication carts observed: Chestnut Medication Cart 2, Evergreen Medication Cart, and Birch Medication Cart 1. Facility policy required opened or accessed multi-dose vials to be dated and discarded within 28 days unless the manufacturer specified otherwise. Manufacturer information reviewed for Dorzolamide eye drops stated they should be discarded 28 days after opening, and manufacturer information for Latanoprost eye drops stated they should be discarded six weeks after opening. During observation of Chestnut Medication Cart 2, one open vial of Lispro insulin was found with an expiration date of September 8, 2025. Observation of Evergreen Medication Cart revealed an open and undated container of Dorzolamide eye drops. Observation of Birch Medication Cart 1 revealed a vial of Lispro insulin with an open date of August 2, 2025 and no expiration date, and this medication had expired on August 29, 2025. The same cart also contained an open container of Latanoprost eye drops with no open date and no expiration date. The issue was conveyed to the Nursing Home Administrator on September 10, 2025.
Failure to Document Actual Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to follow a physician’s order and appropriately monitor fluid intake for one resident who had an active 1500 ml fluid restriction ordered on March 17, 2025. The order specified how the 1500 ml total was to be distributed across nursing shifts and meals, including set amounts for 7 a.m.-3 p.m., 3 p.m.-11 p.m., 11 p.m.-7 a.m., breakfast, lunch, and dinner. The resident’s clinical record also identified diagnoses of acute on chronic diastolic congestive heart failure, end-stage renal disease, and type 2 diabetes mellitus with hyperglycemia. Review of the August MAR showed staff documented only yes or no to indicate whether the resident was compliant with the fluid restriction. Facility policy required licensed staff to document on the eMAR whether the fluid restriction was accepted or not accepted by the resident, but staff did not record the actual amount of fluid consumed. An LPN stated that the MAR did not show whether the resident consumed 500 ml or 1500 ml in a day, only that the resident did not go over 1500 ml in 24 hours. The RD stated that, because of the documentation practice, she was unable to accurately assess the resident’s actual fluid intake. The DON and ADON confirmed these findings.
Failure to Notify Resident Before Room Change
Penalty
Summary
The facility failed to ensure that a resident received appropriate notification before a room change for Resident 16, who had diagnoses including major depressive disorder, diabetes mellitus, and bladder cancer. Review of progress notes showed the resident was sent to the hospital on August 11, 2025, for abdominal pain. While the resident was away, the facility changed the resident’s room. When Resident 16 returned from the hospital on August 14, 2025, the resident was brought by stretcher with two attendants to the assigned room and became upset upon seeing that the room had been changed. The resident screamed that [he/she] was not going into that room and stated, “take me back,” after being told the choice was to accept the room or return to the hospital. The attendants then exited the building with the resident on the stretcher to return to the hospital. The resident later stated that [he/she] was not informed of the room change before it occurred, and the Nursing Home Administrator confirmed that the room was changed while the resident was in the hospital and that no prior notification was provided.
Soiled Privacy Curtains on Dogwood Unit
Penalty
Summary
The facility failed to ensure a clean and homelike environment by not keeping privacy curtains clean when they were visibly soiled. On the Dogwood unit, observation on September 7, 2025, at 12:15 p.m. of 12 rooms found that nine residents' rooms had privacy curtains stained with brown and/or red substances, including the rooms of Resident 7, Resident 22, Resident 47, Resident 50, Resident 53, Resident 54, Resident 56, Resident 59, Resident 68, Resident 78, Resident 88, Resident 94, Resident 108, Resident 112, Resident 121, and Resident 123. During interview, the NHA stated she would investigate the matter, and the DON stated housekeeping usually cleans privacy curtains upon discharge of a resident or when notified the curtains are visibly soiled.
Failure to Provide SNF ABN When Medicare Coverage Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to the resident or the resident's representative when Medicare Part A services ended for two residents. For Resident 7, the last covered day of Medicare Part A services was July 11, 2025, and the SNF beneficiary Protection Notification Review showed the SNF ABN form was not provided; documentation stated it was sent to the family by mail, but it was never returned, and the facility could not provide any further documentation showing the resident or representative was informed of potential non-coverage and the option to continue services with financial liability. For Resident 72, the last covered day of Medicare Part A services was July 24, 2025, and the same review showed the SNF ABN form was not provided; documentation again stated it was sent to the family by mail and never returned, with no further evidence that the resident or representative was notified. The Nursing Home Administrator confirmed on September 10, 2025, that there was no evidence that Residents 2 and 72 were provided with the SNF ABN.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify the physician of a change in a resident's condition as required by facility policy. A resident with diagnoses including severe protein calorie malnutrition, epilepsy, and dysarthria was observed by an LPN to have increased slurred speech, but the LPN did not notify the physician or document the observation, attributing the change to a previous respiratory illness. There was no documentation in the clinical record regarding slurred speech or its worsening during the relevant period. The facility's policy requires staff to notify the physician of significant changes in a resident's physical or mental condition, but this was not followed in this instance. Further review of the resident's record showed that a family member expressed concern about a dramatic negative change in the resident's vocal ability, prompting a nursing supervisor to assess the resident and arrange for hospital transfer. Hospital records indicated the resident presented with worsening dysarthria, confusion, bilateral lower extremity weakness, and was diagnosed with Dilantin toxicity. The failure to notify the physician in a timely manner about the resident's change in condition led to a delay in appropriate medical intervention.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during specific shifts over a period from April 12 through April 21, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift on four separate days, one nurse aide per 11 residents during the evening shift on one day, and one nurse aide per 15 residents during the night shift on one day. These deficiencies were identified through a review of the facility's staffing data and were communicated to the Nursing Home Administrator during a telephone interview on April 23, 2025.
Plan Of Correction
NHA/designee reviewed the CNA day shift ratios for 4/12/25, 4/17/25, 4/20/25, and 4/21/25. The CNA evening shift ratio for 4/21/25 and the CNA night shift for 4/21/25. No grievance or residents care were affected due to staffing. To prevent this from happening again, NHA/designee will re-educate staffing coordinators on correct ratios: one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on the night shift. To monitor and maintain ongoing compliance, NHA/designee will audit nursing schedules weekly x4, then monthly x1, to ensure correct nurse aid ratios. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations as needed.
Failure to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required Per Patient Day (PPD) of 3.2 hours of direct resident care for each resident on seven days between April 12 and April 23, 2025. The specific days and their respective PPDs were as follows: April 12 (3.01), April 13 (3.14), April 14 (3.13), April 17 (3.19), April 19 (3.09), April 20 (3.12), and April 21 (2.83). This deficiency was identified through a review of the facility's staffing data and was communicated to the Nursing Home Administrator during a telephone interview on April 23, 2025.
Plan Of Correction
NHA/designee reviewed the following dates as they were below the required PPD minimum of 3.20: 4/12/25, 4/13/25, 4/14/25, 4/17/25, 4/19/25, 4/20/25, 4/21/25. No grievance or residents care were affected. To prevent this from happening again, NHA/designee will re-educate staffing coordinators on the need for PPD to be at 3.20 or above. To monitor and maintain ongoing compliance, NHA/designee will audit nursing schedules weekly x4, then monthly x1, to ensure correct PPD. The results of the audit will be forwarded to the facility QAPI committee for further review and recommendations as needed.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides across multiple shifts over a period from December 10 through December 19, 2024. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift on five occasions, one nurse aide per 11 residents during the evening shift on two occasions, and one nurse aide per 15 residents during the night shift on four occasions. These deficiencies were identified through a review of the facility's staffing data and were confirmed by the Nursing Home Administrator during a telephone interview on January 6, 2025.
Plan Of Correction
The Cna Day shift Ratio were reviewed for 12/10/2024, 12/11/2024, 12/14/2024, 12/16/2024 and 12/18/2024. The Cna Evening shift ratio were reviewed for 12/16/2024 and 12/17/2024. The Cna Night shift ratio was reviewed for 12/12/2024, 12/16/2024, 12/17/2024 and 12/18/2024. No grievance or residents care were affected due to the staffing. Other Days were reviewed. No residents care were affected due to staffing. Staffing coordinators will be re-educated on correct ratios - one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents on the evening shift and one nurse aide per 15 residents on the night shift. Random Weekly audits will be done by the NHA for 4 weeks. Results will be reviewed in QAPI to see if further action is needed.
Facility Fails to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per patient day (PPD) for nine days between December 10 and December 19, 2024. A review of the facility's staffing data revealed that on these days, the PPD ranged from 2.76 to 3.09, all below the mandated threshold. This deficiency was identified through an analysis of staffing records and was communicated to the Nursing Home Administrator during a telephone interview on January 6, 2025.
Plan Of Correction
The following dates were reviewed as their HPPD were below the required minimum of 3.20: 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/18/2024. No grievance or residents care were affected. Other dates were reviewed to see the HPPD. Residents care was not affected. Staffing coordinator to be re-educated on need for an HPPD at 3.2 or above. Random weekly audits will be done by the NHA to ensure HPPD is correct. Weekly times 4. Results will be reviewed by QAPI to see if further action is needed.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving Resident R1. The Licensed Practical Nurse (LPN) mistakenly administered medications intended for Resident R1's roommate, Resident R2, to Resident R1. This error occurred because the LPN asked Resident R1 if their name was the same as Resident R2's, and Resident R1 incorrectly confirmed. The LPN did not follow the facility's policy of verifying the resident's identity through multiple methods before administering medication. As a result of receiving the wrong medications, Resident R1 experienced a significant drop in blood pressure and heart rate, leading to a medical emergency. The resident was found to have a blood pressure of 72/40 and a heart rate of 42, prompting the on-call physician to direct that the resident be sent to the hospital. Resident R1 was admitted to the Intensive Care Unit (ICU) for monitoring and required inotropic and vasopressor support due to bradycardia and hypotension. The incident was identified as past non-compliance, and the facility's investigation revealed that the LPN did not adhere to the medication administration policy. The error was discovered when the LPN realized that Resident R1 was sitting in the hallway and not in their assigned bed, leading to the recognition that the wrong medications had been given. The facility's documentation confirmed that the LPN failed to follow the proper procedures for verifying resident identity, resulting in the significant medication error and subsequent hospitalization of Resident R1.
Failure to Safely Reheat Beverage Results in Resident Injury
Penalty
Summary
The facility failed to safely reheat a beverage for a resident, resulting in actual harm. The incident involved a resident who requested their coffee to be reheated. The nursing employee reheated the coffee in the microwave for approximately 30 seconds, three times, testing the temperature between each heating. However, there was no documentation or evidence that the beverage's temperature was checked to ensure it was safe before serving. The resident subsequently spilled the coffee on themselves, resulting in second-degree burns on both buttocks. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had requested the coffee to be reheated before bed. The nursing employee left the reheated coffee on the bedside table at the end of their shift. The facility's policy on microwave use required that beverages be checked for a maximum temperature of less than 165 degrees Fahrenheit and allowed to sit for three minutes before serving. The lack of adherence to this policy and the absence of temperature logs contributed to the incident, leading to the resident's injury.
Failure to Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to accurately monitor and assess residents for side effects of antipsychotic medications for three residents. Resident 2 had an order for Abilify 5 mg once daily, but their clinical record did not show evidence of side effect monitoring. Similarly, Resident 84 had an order for Abilify 10 mg once daily, and their clinical record also lacked evidence of side effect monitoring. An interview with a licensed nurse revealed that side effect monitoring should be documented in the residents' Medication Administration Record (MAR), but this was not found for Residents 2 and 84. Resident 93 had an order for Risperidone 0.5 mg twice daily and a specific order to monitor for side effects every shift, with instructions to document 'N' if no side effects were observed and 'Y' if side effects were observed. However, the September 2024 Treatment Administration Record for Resident 93 showed that staff were not documenting 'N' or 'Y' as required, instead using a checkmark and initials. These findings were confirmed with the Director of Nursing.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to adhere to infection prevention measures for COVID-19 on the 1st Floor Chestnut Unit. The facility's policy required staff to use full PPE, including an N95 respirator, gown, gloves, and eye protection, when entering the room of a resident in isolation. However, observations revealed that Licensed Employee E5 did not change PPE between resident rooms while conducting COVID-19 tests. The employee was seen wearing a cover gown, N95, and gloves, and did not change these items or perform hand hygiene between testing different residents. Additionally, the employee placed a second pair of gloves over the first pair without removing or changing the initial pair, further violating infection control protocols. The facility also failed to notify family members or visitors of the presence of COVID-19 in the building. Observations at the entrance and reception area on multiple days showed no evidence of notification or screening procedures for visitors. The Director of Nursing confirmed that all staff should have been wearing face masks and that additional screening should have been conducted at the entrance following the detection of a positive COVID-19 case. This lack of communication and adherence to infection control measures contributed to the deficiency.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident 26 was observed receiving oxygen therapy at 2 liters per minute through a nasal cannula, as per physician's orders for PRN use. However, the resident's active care plan did not include any interventions or a care plan for oxygen therapy. This oversight was confirmed by the Director of Nursing during an interview, indicating a lack of proper documentation and planning for the resident's respiratory needs. Similarly, Resident 93 was found to have a left wrist contracture, with clinical records noting the condition and a recommendation from a hospice nurse to use a rolled-up washcloth to slow its progression. Despite this, the resident's care plan did not address the contracture or the recommended intervention. Observations revealed that the intervention was not implemented, and the Director of Nursing confirmed the absence of an active care plan for the contracture. These deficiencies highlight the facility's failure to ensure that care plans are comprehensive and reflective of residents' current needs.
Failure to Adhere to Fluid Restriction Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding fluid restriction for a resident, identified as Resident 11. The physician's order, dated August 13, 2024, specified a fluid restriction of 1500 ml per day, with 900 ml to be provided by nursing and 600 ml by dietary services. However, a review of the clinical records revealed a lack of documentation regarding the fluid amounts administered by nursing. Additionally, the dietary records showed that the resident consistently consumed more than the prescribed 600 ml from dietary sources on multiple occasions between August 13, 2024, and September 24, 2024. The Director of Nursing confirmed the absence of nursing documentation for the resident's fluid intake and acknowledged that the dietary fluid restriction was not adhered to as ordered by the physician. This deficiency was identified during a survey, and it was noted that similar issues had been previously cited on October 20, 2023, and June 13, 2024, under the Pennsylvania Code 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services.
Lack of Clinical Rationale for Declining Pharmacist's Recommendation
Penalty
Summary
A deficiency was identified in the facility's pharmacy services, specifically related to the drug regimen review process for Resident 102. The Consultant Pharmacy Medication Review conducted on March 27, 2024, included a recommendation for a Gradual Dose Reduction (GDR) which the physician disagreed with. However, the physician failed to provide a clinical rationale for declining the Consultant Pharmacist's recommendation. This lack of documentation was confirmed during an interview with the Director of Nursing on September 25, 2024, indicating non-compliance with the facility's policy and the regulatory requirement under 28 Pa. Code 211.9(a) Pharmacy Services.
Delay in Obtaining X-ray for Resident's Foot Injury
Penalty
Summary
The facility failed to ensure timely radiological diagnostic studies for a resident, leading to a deficiency. A podiatry consult on April 15, 2024, indicated that the resident had fallen a week or two prior and was experiencing pain in the left foot. The podiatrist recommended an x-ray of the left foot. However, the nurse's note from the same day stated that no new orders were received. The x-ray was not obtained until April 23, 2024, revealing a fracture of the distal fifth metatarsal bone. This delay in obtaining the x-ray was confirmed by the Director of Nursing on September 25, 2024.
Failure to Accurately Follow Physician Medication Orders
Penalty
Summary
The facility failed to ensure that physician medication orders were accurately entered and followed for a resident diagnosed with Epilepsy and Irritable Bowel Syndrome (IBS). Upon admission, the resident's hospital discharge summary included a medication order for Prednisone, which was to be taken in a tapering dose starting with four tablets daily for five days. However, the facility's Medication Administration Record (MAR) incorrectly transcribed this order as every five days instead of daily, resulting in the medication being administered only once before the resident left the facility. The licensed nurse involved could not explain why the order was entered incorrectly, and there was no documentation indicating that the physician had altered the hospital's original order. Additionally, the facility failed to administer Mesalamine, prescribed for the resident's IBS, due to the medication's unavailability. Although the physician was initially notified of the missed doses, there was no further notification when the medication continued to be unavailable, leading to additional missed doses. This lack of communication and failure to follow the physician's orders contributed to the deficiency identified by the surveyors.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who required them due to having wounds. The facility's policy, dated April 2024, mandates EBP for residents with wounds or indwelling medical devices, regardless of their Multiple Drug Resistant Organism (MDRO) status. This includes placing appropriate signage at room entrances and ensuring Personal Protective Equipment (PPE) is available for staff before entering the resident's room. However, observations on June 13, 2024, revealed that there was no signage or PPE available at the room entrances of the three residents with wounds. Resident R1 was observed in bed with a dressing on the left foot, and their clinical record confirmed a left heel ulcer. Resident R2's clinical record indicated a sacral pressure ulcer, and Resident R3 had a left lateral foot wound. An interview with a licensed nurse, Employee E5, confirmed the presence of wounds in all three residents and revealed that staff had to request housekeeping to provide PPE when needed. This lack of immediate availability of PPE and absence of signage at the room entrances led to the deficiency in implementing the EBP process for these residents.
Failure to Obtain Physician's Orders for Immediate Care at Admission
Penalty
Summary
The facility failed to ensure that physician's orders for immediate care were obtained at the time of admission for a resident. The resident's hospital discharge documentation indicated the need for follow-up appointments with Nephrology and continuation of dialysis on specific days. The resident's clinical records, including an admission MDS and a care plan, documented the need for dialysis treatments three times a week due to renal insufficiency and end-stage disease. However, the physician's admission orders did not include orders for dialysis. This deficiency was confirmed through an interview with the Nursing Home Administrator (NHA) and Assistant NHA.
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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 Christiana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Tel Hai Retirement Community | 9.1 mi | ★★★★★ | 2 | 0 |
| Quarryville Presbyterian Retirement Community | 10.3 mi | ★★★★★ | 16 | 0 |
| Hickory House Nursing Home | 10.8 mi | ★★★★★ | 10 | 0 |
| Garden Spot Village | 10.8 mi | ★★★★★ | 2 | 0 |
| Preston Residence | 11.2 mi | ★★★★★ | 0 | 0 |
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