Encore At West Meadow
ENCORE AT WEST MEADOW in NEWARK, DE — inspection on October 29, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on record review and interview, it was determined that for four (R1, R2, R3, R4) out of four residents reviewed for admission, the facility failed to provide services that meet the professional standard of quality as defined by the Delaware State Code regarding RN (registered nurse), LPN (licensed practical nurse) and NA (nurse aide)/ UA (unlicensed assistant) Duties for admission assessments.
Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 .admission Assessments *. RN (registered nurse) . *Once a care plan is established, the LPN may do assessments.
Updated 10/11/24Facility admission Assessment and Follow Up: Role of the Nurse policy included a document that listed all the evaluations in the facility EMR that were considered admission Evaluations.
The list included: N Adv- Clinical Admission, N Adv- Skin Check, N Adv- Braden scale- for Predicting Pressure Ulcer Risk Evaluation, N Adv- Lift/Transfer Evaluation, N Adv -Fall Risk Evaluation, N Adv -Dehydration Risk Evaluation, N Adv- Elopement Evaluation, Hot Liquids Safety Data Collection, Functional Abilities and Goals, LCS Bedrail Evaluation, Trauma Informed Care and Baseline Care Plan.1.
Review of R1's clinical record revealed:8/5/25 - R1 was readmitted to the facility.8/5/25 - E6 (LPN) documented and completed in R1's EMR the N Adv-Clinical Admission, N Adv-Braden Scale- for Predicting Pressure Ulcer Risk Evaluation, N Adv- Left/Transfer Evaluation, N Adv-Elopement Evaluation, Functional Abilities and Goals, and N Adv- Dehydration Risk Evaluation.
The facility failed to have a registered nurse complete six of R1's admission evaluations.2.
Review of R2's clinical record revealed: 10/26/25 - R2 was admitted to the facility.10/26/25 - E11 (LPN) documented and completed in R2's EMR the N Adv-Clinical Admission, N Adv-Braden Scale- for Predicting Pressure Ulcer Risk Evaluation, N Adv-Elopement Evaluation, N Adv- Fall Risk Evaluation and N Adv- Dehydration Risk Evaluation.
The facility failed to have a registered nurse complete five of R2's admission evaluations.3.
Review of R3's clinical record revealed: 10/10/25 - R3 was admitted to the facility.10/10/25 - 10/26/25 - E12 (LPN) documented and completed in R3's EMR the N Adv-Clinical Admission, N Adv-Trauma Informed Care, N Adv-Elopement Evaluation, N Adv- Fall Risk Evaluation, N Adv- Lift/Transfer Evaluation and N Adv- Dehydration Risk Evaluation.
The facility failed to have a registered nurse complete six of R3's admission evaluations.4.
Review of R4's clinical record revealed: 10/4/25 - R4 was admitted to the facility.10/4/25 - 10/26/25 - E6 (LPN) documented and completed in R4's EMR the N Adv-Clinical Admission, N Adv-Elopement Evaluation, N Adv- Fall Risk Evaluation, N Adv- Lift/Transfer Evaluation and N Adv- Dehydration Risk Evaluation.
The facility failed to have a registered nurse complete five of R4's admission evaluations.10/29/25 12:35 PM - During an interview, E2 (DON) confirmed that E6, E11 and E12 had completed several of the facility's admission evaluations. 10/29/25 1:45 PM- The findings were reviewed during the exit conference with E1(NHA), E2 (DON), E3 (RDOCS), E4 (RN/UM) and E5 (RN/UM).
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Encore at West Meadow
255 Possum Park Road Newark, DE 19711
SUMMARY STATEMENT OF DEFICIENCIES
residing in the SNF (skilled nursing facility).
Their (R1's) profile was in the IL (independent living). We did not have any allergy information so we had to call the IL to get allergies. On 8/6/25, the facility called and was told there was no script (prescription).
The script was associated with the IL.
The problem was [R1] was profiled as residing in the IL, where she normally lives.
The pharmacy did not know she had been to the hospital and was now in rehab at the SNF. We (pharmacy) typically try not to admit or move the patients in the profiles until they are actually in the facility as this creates an insurance reimbursement issue if the resident ends up not showing up at the facility. On 8/7/25, the facility got the MD (medical doctor) to fill out a new script. He (C1, DO) wrote for 1mg (milligram) of lorazepam BID (twice a day) but the formulation of lorazepam in the E box (emergency medication box) was 0.5 mg, the pharmacy could not release the medication.
The script (prescription) has to match the drug formulation in the E box exactly or regulation or we cannot release the medication. So although there was lorazepam available in the facility, we could not release the medication. We needed the script to say lorazepam 0.5mg four tablets for a 2 mg dose in order to use the meds (medication) for the E box.10/29/25 1:15 PM -
During an interview, E10 (RN) stated that on 8/7, she had requested that C1 write a new script with the available formulation in the E box for the lorazepam, which was 0.5 mg but he [C1] said he had already written one for 1mg lorazepam.
The facility failed to provide routine and emergency drugs to R1.10/29/25 1:45 PM- The findings were reviewed during the exit conference with E1(NHA), E2 (DON), E3 (RDOCS), E4 (RN/UM) and E5 (RN/UM).
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Encore at West Meadow
255 Possum Park Road Newark, DE 19711
SUMMARY STATEMENT OF DEFICIENCIES
received- Tasked [facility pharmacy] with notifying the facility for any new admission medication that requires a prescription and the prescription was not sent directly from the discharging facility- Educated staff members that the providers are to be informed immediately for a recognized failure in obtaining necessary medication- Educated the providers that prescriptions for medications from the Emergency supply box(E Box) must be written in the exact formulation of the drug supplied in the emergency supply box.
The facility alleged that all these corrective actions were completed by 8/8/25 at 11:20 PM.
The surveyor confirmed education with staff during interviews. 8/9/25 - R1 was re-admitted to the facility after hospitalization. 8/11/25 - C1 (DO) documented in R1's EMR re-admission History and Physical note- .
History of Present Illness- .
The patient was readmitted there [hospital] with reported seizure-like activity.
There appeared to be some issues obtaining patient's chronic benzodiazepine therapy from the pharmacy in a timely fashion at the time of admission.
She apparently went 48 hours without a dose of her lorazepam therapy.
Workup at the hospital was largely unremarkable and included EEG monitoring and MRI imaging.
She was evaluated by the neurology team who recommended ongoing benzodiazepine therapy without changes at this time.Diagnosis and Assessment: Seizure- appears to be related to benzodiazepine withdrawal.8/14/25 - C1 (DO) documented in R1's EMR progress note, .Diagnosis and Assessment: Benzodiazepine dependence- secondary to prolonged use of high-dose lorazepam therapy, resulting in withdrawal seizure requiring hospitalization.10/29/25 9:45 AM - A review of R1's MAR revealed the 8/5/25 8PM, 8/6/25 9 AM and 8/7/25 9 AM lorazepam doses were documented as not given/ see nurses notes.
The 8/6/25 8 PM lorazepam dose did not have any documentation in the MAR or progress notes regarding this medication.10/29/25 10:39 AM -
During an interview, E2 (DON) confirmed that R1 did not receive any doses of lorazepam from 8/5/25 to 8/7/25. 10/29/25 1:45 PM- The findings were reviewed during the exit conference with E1(NHA), E2 (DON), E3 (RDOCS), E4 (RN/UM) and E5 (RN/UM).
Facility ID: