Encore At West Meadow: Medication Error Harm - DE
State inspectors found the facility violated professional nursing standards for all four residents they reviewed during an October 29 complaint investigation. The violations occurred between August and October 2025.
Delaware nursing regulations are explicit: registered nurses must complete admission assessments. Licensed practical nurses can only perform assessments after a care plan is established by an RN.
The facility's own policy listed 13 evaluations considered admission assessments, including clinical admission reviews, fall risk evaluations, pressure ulcer risk assessments, and elopement evaluations.
One resident readmitted on August 5 had six admission evaluations completed by LPN E6 instead of a registered nurse. The assessments included clinical admission, pressure ulcer risk, lift and transfer evaluation, elopement evaluation, functional abilities assessment, and dehydration risk evaluation.
A second resident admitted October 26 received five admission evaluations from LPN E11, covering clinical admission, pressure ulcer risk, elopement evaluation, fall risk evaluation, and dehydration risk evaluation.
The pattern repeated with a third resident admitted October 10. LPN E12 completed six assessments between the admission date and October 26, including clinical admission, trauma informed care, elopement evaluation, fall risk evaluation, lift and transfer evaluation, and dehydration risk evaluation.
A fourth resident admitted October 4 had five admission evaluations completed by LPN E6 over more than three weeks, from the admission date through October 26.
The Director of Nursing confirmed during an interview that the three LPNs had completed the admission evaluations. The DON acknowledged that E6, E11, and E12 had performed assessments legally reserved for registered nurses.
Admission assessments establish the foundation for resident care plans and safety protocols. Fall risk evaluations determine whether residents need assistance walking or specialized equipment. Pressure ulcer assessments identify skin breakdown risks requiring preventive positioning and mattresses. Elopement evaluations assess whether residents with dementia might wander away from the facility.
Delaware's nursing practice act updated its admission assessment requirements as recently as October 11, 2024. The regulations specify that only registered nurses can perform initial resident assessments, with LPNs limited to follow-up evaluations after RNs establish care plans.
The facility operates under clear written policies acknowledging these requirements. Their admission assessment policy references the role of nurses and includes documentation listing all evaluations considered admission assessments in their electronic medical record system.
Despite having registered nurses on staff, including RN unit managers E4 and E5 who participated in the exit conference, the facility allowed LPNs to complete legally restricted assessments for weeks.
The violations affected residents across multiple admission dates, suggesting a systematic practice rather than isolated incidents. One LPN completed assessments for residents admitted three weeks apart, indicating the pattern persisted over time.
State inspectors classified the violations as having minimal harm or potential for actual harm to residents. However, the regulatory breach undermines the professional standards designed to ensure qualified nurses make critical initial assessments of resident needs and risks.
The inspection findings were reviewed during an exit conference with the nursing home administrator, director of nursing, regional director of clinical services, and two registered nurse unit managers on October 29.
Federal regulations require nursing facilities to provide services meeting professional quality standards. Delaware's specific nursing practice requirements establish which staff members can legally perform different types of assessments and care planning activities.
The systematic use of LPNs for RN-required admission work represents a fundamental misunderstanding or disregard of professional nursing scope of practice rules designed to protect resident safety during the vulnerable admission period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Encore At West Meadow from 2025-10-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ENCORE AT WEST MEADOW in NEWARK, DE was cited for violations during a health inspection on October 29, 2025.
State inspectors found the facility violated professional nursing standards for all four residents they reviewed during an October 29 complaint investigation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.