Encore At West Meadow: Pharmacy Service Gaps - DE
The facility's own policy lists 13 evaluations considered admission assessments, including clinical admission reviews, fall risk evaluations, pressure ulcer risk assessments, and elopement evaluations. Delaware nursing regulations specify that registered nurses must complete admission assessments, though licensed practical nurses may conduct assessments once a care plan is established.
Federal inspectors found the facility systematically violated these requirements across multiple recent admissions.
On August 5, a resident readmitted to the facility received six admission evaluations from E6, a licensed practical nurse. The LPN completed the clinical admission assessment, pressure ulcer risk evaluation, lift and transfer evaluation, elopement evaluation, functional abilities assessment, and dehydration risk evaluation.
No registered nurse performed any of these required assessments.
Three weeks later, on October 4, another resident's admission followed the same pattern. The same LPN, E6, completed five admission evaluations including clinical admission, elopement evaluation, fall risk evaluation, lift and transfer evaluation, and dehydration risk evaluation. Again, no registered nurse conducted the legally mandated assessments.
The violations continued through October. On October 10, a third resident's admission assessments were handled by E12, another licensed practical nurse. This LPN completed six evaluations over more than two weeks, including clinical admission, trauma informed care assessment, elopement evaluation, fall risk evaluation, lift and transfer evaluation, and dehydration risk evaluation.
The most recent case occurred October 26, when E11, a third licensed practical nurse, completed five admission evaluations for a newly admitted resident. These included clinical admission, pressure ulcer risk evaluation, elopement evaluation, fall risk evaluation, and dehydration risk evaluation.
The pattern revealed systematic delegation of legally protected nursing duties to staff without proper credentials.
During the inspection, the director of nursing confirmed that the three licensed practical nurses had completed multiple facility admission evaluations. The director acknowledged the practice during a 12:35 PM interview on October 29.
Delaware nursing regulations, updated as recently as October 11, 2024, explicitly reserve admission assessments for registered nurses. The state board of nursing specifies that while LPNs may conduct assessments after care plans are established, initial admission evaluations require RN credentials.
The facility's admission assessment policy includes a comprehensive list of required evaluations stored in the electronic medical record system. These range from basic clinical admission reviews to specialized assessments for fall risk, pressure ulcer development, and resident safety concerns like elopement potential.
Federal inspectors classified the violations as having minimal harm or potential for actual harm to residents. However, the systematic nature of the violations across four consecutive admissions suggests an institutional practice rather than isolated incidents.
The inspection findings were reviewed during an exit conference with facility leadership including the nursing home administrator, director of nursing, and multiple registered nurses serving as utilization managers.
Admission assessments serve as the foundation for resident care plans and safety protocols. These evaluations determine fall prevention strategies, pressure ulcer prevention measures, and other critical safety interventions. When conducted by improperly credentialed staff, the assessments may miss important clinical indicators or fail to establish appropriate care parameters.
The facility operates under federal Medicare and Medicaid certification, which requires compliance with both federal nursing home regulations and applicable state professional licensing laws. Delaware's nursing practice act establishes clear boundaries between registered nurse and licensed practical nurse responsibilities, with admission assessments falling squarely within RN scope of practice.
The October 29 inspection was conducted in response to complaints about the facility. Federal regulators found the professional standards violations affected some residents, indicating the practice was not isolated to the four cases documented in detail.
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.
Federal inspectors found the facility systematically violated these requirements across multiple recent admissions.
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.