Inspection Report Summary
The most recent inspection on December 8, 2025, found the facility to be in substantial compliance with no deficiencies. Earlier inspections showed a pattern of deficiencies related to resident care, including issues with timely physician notification, supervision, care planning, and safety hazards involving bed rails. Prior reports also cited concerns about abuse and neglect, emergency preparedness, staffing levels, infection control, and documentation. Several complaint investigations were substantiated, including cases of resident harm from falls and physical abuse, as well as failure to meet staffing and safety requirements. The facility appears to have addressed many prior deficiencies by the latest follow-up survey, indicating improvement over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
58 residents
Based on a December 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 58
Deficiencies: 0
Date: Dec 8, 2025
Visit Reason
An unannounced Follow-Up Survey to the Complaint Survey ending October 24, 2025, was conducted to verify compliance and review residents' clinical records and other documentation.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of November 21, 2025.
Report Facts
Survey sample size: 10
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 8
Date: Oct 24, 2025
Visit Reason
An unannounced Complaint Survey was conducted at Newark Manor Nursing Home from October 21, 2025, through October 24, 2025, based on observations, interviews, and review of residents' clinical records and other facility documents.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to notify the physician timely of STAT x-ray results, failed to investigate and prevent neglect when a resident was left unattended resulting in a fall, and failed to provide adequate supervision and care planning for residents using bed rails, leading to injuries and safety hazards.
Findings
The survey identified multiple deficiencies related to notification of changes, investigation and prevention of alleged violations, development and implementation of comprehensive care plans, bed rail safety, accident hazards, and radiology services. The facility failed to ensure timely physician notification, adequate supervision, proper documentation, and appropriate care planning, resulting in resident harm and safety risks.
Deficiencies (8)
Failure to notify physician timely of STAT x-ray results and delays in communication of urgent diagnostic results.
Failure to investigate, prevent, and correct alleged violation of neglect when resident was left unattended leading to a fall.
Failure to develop and implement a comprehensive, person-centered care plan for residents including those with implanted cardiac devices.
Failure to ensure bed rail care plans were person-centered and to monitor and supervise residents using bed rails or enablers.
Failure to ensure free of accident hazards and adequate supervision to prevent falls and injuries related to bed rails.
Failure to ensure timely and accurate assessment, monitoring, and documentation of residents with dementia and high fall risk.
Failure to ensure appropriate use, maintenance, and monitoring of bed rails including staff education and resident consent.
Failure to ensure timely and adequate radiology and diagnostic services for residents including timely STAT x-rays.
Report Facts
Facility census: 59
Survey sample size: 9
Fall incident dates: 7
Audit duration: 4
Audit duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Hodgdon | Director of Nursing | Re-educated nursing and MDS staff on person-centered care planning and bed rail policies |
| Beth Carroll | RN Supervisor | Received a written disciplinary action related to fall incident investigation |
| Monica Thompson | CNA | Terminated on 09/15/25 related to failure to provide supervision and falsifying information |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 9
Date: Feb 19, 2025
Visit Reason
An unannounced annual and complaint survey was conducted at Newark Manor Nursing Home from February 13, 2025 through February 19, 2025 to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies related to abuse and neglect, accuracy of assessments, quality of care, respiratory care, dietary support, food safety, resident records confidentiality, infection prevention and control, and antibiotic stewardship. Corrective actions and staff education plans were outlined for each deficiency.
Deficiencies (9)
Facility failed to ensure a resident was free from physical abuse resulting in a broken nose and laceration.
Facility failed to ensure accuracy of assessments for one resident.
Facility failed to ensure physician's order was followed for medication administration for one resident.
Facility failed to ensure supplemental oxygen tubing was changed per standard of practice for one resident.
Facility failed to employ sufficient dietary support personnel with appropriate competencies.
Facility failed to ensure food items were stored and prepared under sanitary conditions.
Facility failed to maintain confidentiality and accuracy of resident medical records.
Facility failed to implement an effective infection prevention and control program including enhanced barrier precautions.
Facility failed to implement an antibiotic stewardship program to monitor antibiotic use.
Report Facts
Facility census: 62
Survey sample size: 16
Deficiency counts: 9
Certified Food Protection Manager test date: Apr 15, 2024
Oxygen tubing replacement frequency: 7
Staff education completion dates: Feb 28, 2025
Plan of correction completion dates: Mar 7, 2025
CFPM test date: Apr 15, 2024
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 4
Date: Jan 11, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality from 01/08/24 through 01/11/24.
Complaint Details
The complaint investigation included review of incidents involving resident-to-resident physical aggression, failure to prevent abuse, and failure to provide required notices for transfers and discharges. The complaint was substantiated as evidenced by findings of abuse and neglect and failure to comply with notice requirements.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to emergency preparedness, freedom from abuse and neglect, and notice requirements before transfer or discharge.
Deficiencies (4)
Failure to develop and maintain a comprehensive emergency preparedness program that meets federal, state, and local requirements, including annual reviews and updates.
Failure to ensure residents were free from abuse for two residents reviewed, including incidents of physical aggression between residents.
Failure to provide written notice of transfer or discharge to residents or their responsible parties in a timely manner for two residents reviewed.
Failure to provide written information regarding the facility's bed hold policy to residents and responsible parties upon admission and at time of transfer for three residents reviewed.
Report Facts
Survey Census: 59
Sample Size: 26
Deficiencies with Severity SS=D: 3
Bed Hold Payment: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident-to-resident altercation and notification policies |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding notification of resident transfers and bed hold notices |
| Administrator | Administrator | Interviewed regarding emergency preparedness and resident incident |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) 1 | Witnessed resident incident and provided statement |
| Registered Nurse | Registered Nurse (RN) 1 | Provided witness statement regarding resident incident |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 4
Date: Feb 25, 2022
Visit Reason
An unannounced Complaint Survey was conducted at Newark Manor Nursing Home from February 16, 2022 through February 25, 2022 based on observations, interviews, and review of residents' clinical records and other documentation.
Complaint Details
The survey was complaint-driven, initiated due to allegations related to staffing shortages, failure to report crimes, inadequate supervision leading to resident elopement, and COVID-19 vaccination compliance issues. The complaint was substantiated as evidenced by multiple deficiencies.
Findings
The facility was found out of compliance with Delaware Code Chapter 11 Nursing Facilities and Similar Facilities, including failure to meet minimum staffing requirements and deficiencies related to reporting reasonable suspicion of a crime, free of accident hazards, and COVID-19 vaccination policies for staff.
Deficiencies (4)
Failure to meet minimum staffing level of 3.28 hours of direct care per resident per day for two days out of 21 days reviewed.
Failure to develop and implement policies and procedures for reporting reasonable suspicion of a crime, including employee rights and posting requirements.
Failure to provide adequate supervision and a safe environment free of accident hazards for residents, including a missing resident incident and inadequate elopement prevention measures.
Failure to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19, including tracking and exemptions.
Report Facts
Facility census: 57
Staffing hours per resident per day: 3.28
Days out of compliance: 2
Survey dates: 2022-02-16 to 2022-02-25
Survey sample size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding staffing and crime reporting deficiencies |
| E2 | Director of Nursing (DON) | Interviewed and involved in exit conference and staffing issues |
| E3 | Assistant Director of Nursing (ADON) | Interviewed regarding missing resident incident and elopement policy |
| E4 | Environmental Health Services Director (EHSD) | Interviewed about wander alert system and exit alarms |
| E5 | Staff Educator | Interviewed about staff education and missing resident drill |
| E6 | Licensed Practical Nurse (LPN) | Involved in missing resident incident |
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