Newark Manor Nursing Home
NEWARK MANOR NURSING HOME in NEWARK, DE — inspection on October 24, 2025.
Found 7 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 interview and review of clinical record, it was determined that for one (R1) out of three residents reviewed for accidents, the facility failed to notify the on-call provider of R1's delayed STAT x-ray results ordered 7/18/25.
Findings include:Cross refer to F-F689, example 1 Review of R1's clinical record revealed: 7/18/25 - A physician's order stated to obtain a STAT elbow x-ray for 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 - 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 R1's POA was very upset and requested R1 to be sent to the ER.
E6 stated that the on-call provider was notified and an order to send R1 to the ER (emergency room) for an x-ray was obtained. R1 was sent to the ER at 5:10 PM.
The facility lacked evidence that 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
Facility ID:
08A020
IDENTIFICATION NUMBER:
08A020
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Newark Manor Nursing Home
254 West Main Street Newark, DE 19711
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, record review and other facility documentation, it was determined that for one (R2) out of three residents sampled for falls, the facility failed to thoroughly investigate an allegation of neglect when 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 - 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 - R2's fall care plan documented, Resident with poor safety awareness and impulse control.8/30/25 2:41 PM - 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 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 [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 R2 was left unattended in the bathroom while the CNA went down the hall to obtain an incontinent brief.
When she returned, R2 had fallen to the floor. E7 put R2 into the wheelchair and told the supervisor that [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 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 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).
Facility ID:
08A020
IDENTIFICATION NUMBER:
08A020
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Newark Manor Nursing Home
254 West Main Street Newark, DE 19711
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and review of clinical record, it was determined that for one (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 R1's medical need with respect to the resident's pacemaker.
Findings include: Review of R1's clinical record revealed: 1/31/23 - 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 R1 had a pacemaker on her left upper chest. 1/31/23 - 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 R1's pacemaker care plan was person-centered.
Specifically, the care plan lacked 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 R1's Cardiologist; and monitoring of skin integrity at location site. 10/23/25 approximately 3:00 PM -
During an interview, surveyor reviewed that 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.
Facility ID:
08A020
IDENTIFICATION NUMBER:
08A020
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Newark Manor Nursing Home
254 West Main Street Newark, DE 19711
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview and review of clinical record, it was determined that for three (R1, R4 and 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 R1's clinical record revealed: 3/7/23 - 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. 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 R4's clinical record revealed: 5/17/24 - 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. 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 R5's clinical record revealed: 7/3/24 (last revised) - 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. 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 R5's care plan for a right sided bed enabler, observations of 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.
Facility ID:
08A020
IDENTIFICATION NUMBER:
08A020
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Newark Manor Nursing Home
254 West Main Street Newark, DE 19711
SUMMARY STATEMENT OF DEFICIENCIES
The facility failed to identify 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).
Facility ID:
08A020
IDENTIFICATION NUMBER:
08A020
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Newark Manor Nursing Home
254 West Main Street Newark, DE 19711
SUMMARY STATEMENT OF DEFICIENCIES
During incontinent care, R4 required two staff assist for rolling left and right in bed. 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 R4 required staff assistance for turning in bed. 3.
Review of 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 R5 in bed revealed bilateral bed rails in the up position and head of bed elevated approximately 30 degrees. 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 R5 had bilateral bed rails in the up position. R5 was observed in bed with the right elbow bent and laying on top of the right-sided bed rail.
During incontinent care, R5 required two staff assist. R5 was observed grabbing and holding onto the left bed rail with his right hand during incontinent care.
However, 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).
Facility ID:
08A020
IDENTIFICATION NUMBER:
08A020
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Newark Manor Nursing Home
254 West Main Street Newark, DE 19711
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and review of clinical records and facility documentation, it was determined that for one (R1) out of three residents reviewed for accidents, the facility failed to meet the acute medical needs of R1 with regard to obtaining the timeliness of STAT x-ray results on 7/18/25.
Findings include: Review of 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, 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).
Facility ID:
08A020