Newark Manor Nursing Home

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on interview and review of clinical record, it was determined that for one (Resident R1) out of three residents reviewed for accidents, the facility failed to notify the on-call provider of Resident R1's delayed STAT x-ray results ordered 7/18/25. Findings include:Cross refer to F-F689, example 1 Review of Resident R1's clinical record revealed: 7/18/25 - A physician's order stated to obtain a STAT elbow x-ray for Resident R1's increased pain and decreased movement of left arm. A nursing note, at 5:49 PM, documented that the x-ray was completed in the facility. 7/20/25 8:20 PM - Resident R1's mobile STAT x-ray results were finally read and faxed to the facility revealing a left humeral neck fracture. 10/23/25 11:00 AM - During an interview, E6 (RN) stated that she called the mobile x-ray company on 7/19/25 and was told they were running behind. E6 stated that she did not notify the on-call provider. E6 stated that when she returned to work on 7/20/25 evening shift and found out the results were still not received. E6 stated Resident R1's POA was very upset and requested Resident R1 to be sent to the ER.

E6 stated that the on-call provider was notified and an order to send Resident R1 to the ER (emergency room) for an x-ray was obtained. Resident R1 was sent to the ER at 5:10 PM. The facility lacked evidence that Resident R1's physician or

an on-call provider was notified that the physician ordered STAT x-ray results were not received until approximately 48 hours later. 10/24/25 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA) and E2 (DON).

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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

08A020

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

08A020

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Newark Manor Nursing Home

254 West Main Street Newark, DE 19711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, record review and other facility documentation, it was determined that for one (Resident R2) out of three residents sampled for falls, the facility failed to thoroughly investigate an allegation of neglect when Resident R2 was left unattended in the bathroom and had a fall. Findings include: An undated facility document entitled, Falls included, . The nurse and charge nurse are to be notified immediately, and the resident is not to be moved until assessed by a nurse unless otherwise directed.2/28/22 - Resident R2 was admitted to facility with diagnoses including but not limited to dementia, left eye absolute glaucoma (permanent vision loss), and difficulty walking.1/16/24 - Resident R2's fall care plan documented, Resident with poor safety awareness and impulse control.8/30/25 2:41 PM - Resident R2's clinical record documented, .S/P [status post] fall hit head, has a superficial laceration to the back of the right side of head that is 0.5cm.8/30/25 7:40 PM - A facility reported incident submitted to the Division documented, Resident found on the floor in the bathroom of the third-floor day room.8/30/25 7:47 PM - E8 (LPN) documented in Resident R2's clinical record, At approximately 1400 [2:00 PM], staff reported an unwitnessed fall in the dining room immediately after lunch. Resident was noted on the floor in a seated/side-lying position with active bleeding from the head.10/21/25 1:30 PM - A

review of the facility's post-fall investigative record revealed, During the multidisciplinary care conference for [Resident R2] on 9/11/25, it was brought to the attention of staff that the fall occurred in the bathroom after the resident was left unattended by the CNA [E7.] The CNA misrepresented the location and details of the incident. The facility's new investigation revealed that Resident R2 was left unattended in the bathroom while the CNA went down the hall to obtain an incontinent brief. When she returned, Resident R2 had fallen to the floor. E7 put Resident R2 into the wheelchair and told the supervisor that [Resident R2] had fallen in the dining room.10/21/25 2:30 PM During an interview, the Surveyor asked E8 (LPN) if she had seen or assessed Resident R2 post fall, E8 stated, No, I was on break, and I did not see her on the floor after the fall. The RN supervisor [E5] told me that she had fallen.10/22/25 2:45 PM - During an interview, the Surveyor asked E6 (3-11RN supervisor) how she became aware of the location of Resident R2's fall. E6 stated, The day shift supervisor [E5] told me that the aide said that the resident had fallen in the bathroom. The location was on the report that I submitted to the state.The facility failed to thoroughly investigate the location of the fall until 12 days after the event. 10/24/25 12:00 PM - Findings were confirmed with E2 (DON).10/24/25 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA) and E2 (DON).

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

08A020

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

08A020

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Newark Manor Nursing Home

254 West Main Street Newark, DE 19711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on interview and review of clinical record, it was determined that for one (Resident R1) out of three residents reviewed for accidents, the facility failed to ensure a person-centered care plan was initiated and implemented that included measurable objectives and timeframes to meet Resident R1's medical need with respect to the resident's pacemaker. Findings include: Review of Resident R1's clinical record revealed: 1/31/23 - Resident R1 was admitted to the facility with diagnosis that included, but was not limited to, dementia, legal blindness and sick sinus syndrome. 1/31/23 2:15 PM - The Resident Assessment-Data Collection Form documented that Resident R1 had a pacemaker on her left upper chest. 1/31/23 - Resident R1 was care planned for a pacemaker r/t [related to] sick sinus syndrome with goals and interventions that included: Goals:-will remain free from s/sx [signs/symptoms] of pacemaker malfunction or failure through the review date.Interventions:-Monitor vital signs monthly and as needed. Notify MD (medical doctor) of significant abnormalities. Notify MD of significant abnormalities.-Monitor/document/report PRN (as needed) any s/sx of altered cardiac output or pacemaker malfunction: dizziness, syncope (fainting), difficulty breathing (dyspnea), pulse rate lower than programmed rate, lower than baseline B/P (blood pressure). The facility failed to ensure that Resident R1's pacemaker care plan was person-centered. Specifically, the care plan lacked Resident R1's pacemaker's function information (type, settings/rate, battery status); education for the resident/family on the purpose and function of the pacemaker, signs and symptoms of pacemaker complications and the importance of follow-up appointments with Resident R1's Cardiologist; and monitoring of skin integrity at location site. 10/23/25 approximately 3:00 PM - During an interview, surveyor reviewed that Resident R1's pacemaker care plan was not person-centered with E2 (DON). 10/24/25 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA) and E2.

Event ID:

Facility ID:

08A020

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

08A020

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Newark Manor Nursing Home

254 West Main Street Newark, DE 19711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on observation, interview and review of clinical record, it was determined that for three (Resident R1, Resident R4 and Resident R5) out of seven residents reviewed for bed rails, the facility failed to review and revise each resident's bed rail care plan to ensure they were person-centered to meet their medical needs and included, but were not limited to, ongoing assessment and monitoring of the bed rail usage. Findings include:1. Review of Resident R1's clinical record revealed: 3/7/23 - Resident R1 was care planned for left bed enabler for assistance to change position while in bed. Interventions included:- Document that the enabler is being used to help assist resident to change position in bed;-Ensure a valid consent is on chart prior to initiating enabler; and-Obtain order for enabler. Resident R1's bed rail care plan lacked evidence of the monitoring and supervision to be provided during the use of the bed rail; ongoing assessment to make sure that the bed rail was used to meet the resident's needs; ongoing evaluation of risks; identification of the person who will determined when the bed rail will be discontinued, and the identification and interventions to address any adverse effects of the bed rail use. 10/23/25 approximately 3:00 PM - During an interview, finding was reviewed with E2 (DON). 2. Review of Resident R4's clinical record revealed: 5/17/24 - Resident R4 was care planned for right side rail enabler to assist with changing position while in bed. Interventions were:- anticipate and meet the resident's needs;-document the rail is being used to help assist the resident in changing position;-ensure a valid consent is in the chart prior to initiating rail;-obtain order for rail enabler; and-PT referral as ordered by MD. Resident R4's bed rail care plan lacked evidence of the monitoring and supervision to be provided during the use of the bed rail; ongoing assessment to make sure that the bed rail was used to meet the resident's needs; ongoing evaluation of risks; identification of the person who will determined when the bed rail will be discontinued, and the identification and interventions to address any adverse effects of the bed rail use. 10/23/25 approximately 3:00 PM - During an interview, finding was reviewed with E2 (DON). 3. Review of Resident R5's clinical record revealed: 7/3/24 (last revised) - Resident R5 was care planned for . right sided bed enabler for assistance to change position while in bed. Interventions were:- anticipate and meet the resident's needs;-document the rail is being used to help assist the resident in changing position while in bed; and-ensure a valid consent is in the chart prior to initiating rail. Resident R5's bed rail care plan lacked evidence of the monitoring and supervision to be provided during the use of the bed rail; ongoing assessment to make sure that the bed rail was used to meet the resident's needs; ongoing evaluation of risks; identification of the person who will determined when the bed rail will be discontinued, and the identification and interventions to address any adverse effects of the bed rail use. 10/23/25 7:20 AM and 11:38 AM - Despite Resident R5's care plan for a right sided bed enabler, observations of Resident R5 in bed revealed that bilateral bed rails in the up position were still being used. 10/23/25 approximately 3:00 PM - During an interview, finding was reviewed with E2 (DON). 10/24/25 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2.

Event ID:

Facility ID:

08A020

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

08A020

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Newark Manor Nursing Home

254 West Main Street Newark, DE 19711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

and told her that it hurts. E10 stated that she immediately knew something was wrong as this was an unusual response of Resident R1. E10 stated that she immediately reported this complaint of pain to the assigned nurse. 10/24/25 11:00 AM – During an interview, E11 (CNA) stated that Resident R1 could not turn in bed. E11 stated that Resident R1 always kept her hands together and left elbow bent.

The facility failed to identify Resident R1's right sided bed rail as a potential accident hazard. 10/24/25 2:30 PM – Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

08A020

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

08A020

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Newark Manor Nursing Home

254 West Main Street Newark, DE 19711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

left and right in bed. 10/23/25 1:15 PM - An observation during care revealed that Resident R4 had a right sided bed rail in the up position. E10 (CNA) was observed removing the therapy carrot device from Resident R4's left contracted hand. During incontinent care, Resident R4 required two staff assist for rolling left and right in bed. Resident R4 was observed and the resident stated that he was not able to grab the right bed rail with his left contracted hand to roll in bed. Immediately after the observation, E10 confirmed that Resident R4 required staff assistance for turning in bed. 3. Review of Resident R5's clinical record revealed: 7/3/24 - A physician's order stated, May use right side bed enabler to assist with turn and repositioning. 10/23/25 7:20 AM - Despite having a physician's order for only one bed rail, an observation of Resident R5 in bed revealed bilateral bed rails in the up position and head of bed elevated approximately 30 degrees. Resident R5 was sleeping with the right elbow bent and laying on top of the right sided bed rail and right hand under his head. The left hand was in a fist and laying on his chest. 10/23/25 11:05 AM - During an interview, E12 (ES) confirmed that the facility did not have evidence of preventive maintenance/safety checks of the bed rails that are currently being used in the facility. E12 provided the manufacturer's guidelines for the bed rails being used. 10/23/25 11:38 AM - An observation

during incontinent care revealed that Resident R5 had bilateral bed rails in the up position. Resident R5 was observed in bed with the right elbow bent and laying on top of the right-sided bed rail. During incontinent care, Resident R5 required two staff assist. Resident R5 was observed grabbing and holding onto the left bed rail with his right hand during incontinent care. However, Resident R5 was not able to use the right sided bed rail for turning during care with his left hand and required two staff assist for turning and repositioning. The facility failed to ensure each residents' bed rail(s) were used appropriately with ongoing monitoring. In addition, the facility lacked evidence that preventive maintenance/safety checks were being completed of all bed rails being used in the facility. 10/24/25 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Event ID:

Facility ID:

08A020

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

08A020

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Newark Manor Nursing Home

254 West Main Street Newark, DE 19711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0776

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and review of clinical records and facility documentation, it was determined that for one (Resident R1) out of three residents reviewed for accidents, the facility failed to meet the acute medical needs of Resident R1 with regard to obtaining the timeliness of STAT x-ray results on 7/18/25. Findings include: Review of Resident R1's clinical record revealed: 7/18/25 - A physician's order stated, Elbow X-ray: Including the humerus, radius, and ulna, for fractures, dislocations, or deformities R/T [related to] increased pain and decreased movement. STAT for Increased pain and decreased movement of LEFT arm. 7/20/25 8:20 PM Approximately 48 hours later, Resident R1's mobile x-ray results were faxed to the facility and documented an acute nondisplaced fracture of the left humeral neck. 10/23/25 12:18 PM - During an interview, C2 (Representative with X-ray company) stated that STAT x-ray results are usually completed in two hours on

the same day ordered. C2 confirmed that on the weekend of 7/18/25 through 7/20/25, the company had limited staff coverage for reading x-rays. C2 stated that the x-ray company notified the facility on 7/20/25 at 2:28 PM that the next available reading would be on 7/20/25 approximately 8:30 PM. 10/24/25 2:30 PM Finding was reviewed during the exit conference with E1 (NHA) and E2 (DON).

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

08A020

If continuation sheet