Newton Presbyterian Manor

In the surveyor’s words

From the most serious findings on record at Newton Presbyterian Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF604Feb 16, 2022

  The facility reported a census of 48 residents with one resident reviewed for physical restraints. Based on record review and interview, the facility failed to ensure that Resident (R) 1 remained free from physical restraints on 11/03/21, when the resident had escalating behaviors in the memory care unit during medication administration. Licensed Nurse (LN) G failed to appropriately respond to the agitated state of R1, which resulted in a physical altercation. LN G called for help from additional staff and the response from multiple staff members caused a higher escalation in the resident's behaviors which resulted in five staff members holding the resident down on the floor. […]

• Actual harm, isolatedF686Feb 25, 2026

  The facility identified a census of 53 residents, with 14 residents sampled, including two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to identify and implement pressure ulcer preventative measures, consistent with professional standards of practice, to prevent the development of a facility acquired stage three pressure ulcer to Resident (R)53's left heel after R53 returned from the hospital, due to surgical repair of her left hip fracture.Findings included:- R53's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder… […]

• Actual harm, isolatedF689Feb 25, 2026

  The facility had a census of 53 residents and the sample included 14 residents. Based on observations, record review and interview, the facility failed to ensure an environment free of accident hazards for Resident R 53 who obtained ahip fracture during a fall and R23 when a Certified Nurse Aide transferred her without a gait belt causing a fall.Findings included:- R53's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), displaced fracture (traumatic bone break where two ends of the bone separate out of their normal positions) intertrochanteric (the area of the hip/thigh bone located between the greater and lesser trochanters left femur (thigh bone), and muscle weakness. […]

• Actual harm, isolatedF689Dec 18, 2024

  The facility reported a census of 49 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to prevent an injury to dependent Resident (R) 1 when staff failed to transfer the resident according to the resident's plan of care with two staff present. This failure resulted in R1 obtaining a 2-to-3-centimeter (cm) laceration (a cut in body skin) on her left lower extremity, which required transport to the Emergency Department and 10 sutures to treat the wound. […]

• Actual harm, isolatedF689May 25, 2022

  The facility reported a census of 55 residents and identified 25 residents as elopement risks. The sample included four residents reviewed for accidents/elopement (exit of facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure two of the four sampled residents remained safe including Resident (R) 2 for staff failure to secure an oxygen tank during the resident's shower. When Certified Medication Aide (CMA) R removed the oxygen tank from the secured back of the resident's wheelchair and set it unsecured on the floor, she knocked the oxygen tank over onto the resident's left foot, causing a fracture of the left great toe. […]