Encore At West Meadow: Medication Error Harm - DE
The problem started with how the pharmacy tracked her. The resident, identified in inspection records only as R1, normally lived in the facility's independent living section. When she was hospitalized and then moved into the skilled nursing unit for rehabilitation, the pharmacy never updated her profile. It still showed her as an independent living resident. Her allergy information wasn't on file for the SNF side, and no prescription had transferred over. Staff had to call the independent living unit just to get her allergy history.
The pharmacy explained why it hadn't moved her record sooner. A pharmacist told inspectors the company typically waits until a resident is physically present before updating profiles, because updating too early creates insurance reimbursement problems if the patient never actually arrives.
On August 7, the facility's medical director wrote a new prescription, but he wrote it for lorazepam 1 mg, twice daily. The emergency medication box at the facility contained only the 0.5 mg formulation. The pharmacy said it couldn't release the medication unless the prescription matched the formulation in the box exactly. To use what was already on hand, the prescription needed to specify four tablets of 0.5 mg for a 2 mg dose.
A registered nurse told inspectors she asked the doctor that same day to rewrite the prescription to match the available formulation. He declined, saying he had already written one for 1 mg.
The lorazepam sat in the emergency box, usable by no one, while the prescription sat on paper, fillable by no one.
Inspectors cited the facility for failing to provide routine and emergency drugs to the resident. The deficiency was classified as minimal harm or potential for actual harm.
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: August 5, 2026 · Our methodology
ENCORE AT PARKSIDE in NEWARK, DE was cited for violations during a health inspection on October 29, 2025.
The problem started with how the pharmacy tracked her.
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.