Newark Manor Nursing Home

In the surveyor’s words

From the most serious findings on record at Newark Manor Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 25, 2022

  Based on observation, record review, interviews, review of the facility's policies and procedures, and review of the police report, it was determined that the facility failed to provide adequate supervision and an environment as free of accident hazards as possible for one (R1) out of four (4) sampled residents. R1, a resident known with a behavior of wandering and assessed as an elopement risk was identified as missing on [DATE] at approximately 11:55 AM. At 2:07 PM, R1 was found outside, unresponsive, stiff, skin cold to touch, without a pulse, and was pronounced deceased at 2:43 PM. […]

• Actual harm, isolatedF689Oct 24, 2025

  Based on interview and review of clinical record and facility documentation, it was determined that for two (R1 and R2) out of three residents reviewed for accidents, the facility failed to ensure each resident received adequate supervision to remain free of accident hazards. For R1, the facility failed to identify that R1's left bed rail was a potential hazard. R1, a dependent resident with dementia, was identified with a change of condition on 7/18/25 and diagnosed with a left upper extremity fracture. The facility's investigation documented that R1 sustained the injury as an accidental contact with the bed enabler during care. As a result, R1 was harmed. […]

• Actual harm, isolatedF600Feb 19, 2025

  Based on interview, record review and review of other documentation as indicated, it was determined that for one (R462) out of three residents reviewed for abuse, the facility failed to ensure that R462 was free from physical abuse by R461 resulting in harm when R462 obtained a broken nose and laceration to the bridge of nose. Due to the facility's corrective measures completed on 5/28/24, the facility was notified that R462's incident was a harm past non-compliance. Findings include: Cross refer F684 The facility's undated policy, titled, Freedom from Abuse, Neglect, Mistreatment, Serious Injury, Misappropriation of Property, Exploitation, Injury of Unknown Origin and Crime documented, .Definitions: 1. […]

• No harm, potential for more than minimal, patternF608Feb 25, 2022

  Based on observation, interview and review of the facility's policy and procedure (P & P), it was determined that the facility failed to develop and implement a P & P that included requirements for the reporting of reasonable suspicion of a crime. In addition, the facility failed to ensure that notice of employee rights for the reporting of reasonable suspicion of crime was posted. Findings include: Review of the facility's P & P titled Freedom From Abuse, Neglect, Mistreatment, Serious Injury, Misappropriation of Property, Exploitation, Sexual Abuse, and Injury of Unknown Origin, dated 1/18/18, lacked evidence of requirements for the reporting of reasonable suspicion of a crime. […]

• No harm, potential for more than minimal, patternF657Dec 21, 2021

  Based on record review and interview it was determined that for three (R19, R40 and R55) out of 31 residents reviewed for care plans, the facility failed to ensure that care plan meetings included the required IDT (interdisciplinary team) attended. Findings include: 1. Review of R19's clinical record and interviews revealed: There were three quarterly MDS assessments completed for R19 on 3/17/21, 6/17/21 and 9/17/21. 12/15/21 12:34 PM - During an interview, FM2 stated that I have never been involved in any care plan meetings, they notify me of changes in condition or medications either over the phone or in person when I'm visiting my (R19). 12/18/21 10:12 AM - During an interview with E2 (DON), it was confirmed that the facility has not been holding care plan meetings for some time. […]