Pennsylvania Department of Health
NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER
Inspection Results For:

There are 185 surveys for this facility. Please select a date to view the survey results.

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NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey and an Abbreviated Complaint Survey, completed September 10, 2025, it was determined that Newport Meadows Health and Rehabilitation Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations: Number of residents sampled:Number of residents cited: Based upon review of facility policy and procedure and observation, it was determined that the facility failed to ensure appropriate storage and labeling of medications in three of four medication carts observed (Chestnut Medication Cart 2, Evergreen Medication Cart, and Birch Medication Cart 1). Findings include: Review of facility policy and procedure titled Medication Labeling and Storage revealed multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of manufacturer information for Dorzolamide Eye drops (medication used for glaucoma treatment) revealed Dorzolamide eye drops should be discarded 28 days after opening. Review of manufacturer information for Latanoprost Eye drops (medication used for glaucoma treatment) revealed Latanoprost eye drops should be discarded six weeks after opening. Observation of the Chestnut Medication Cart 2 on September 9, 2025, at 11:15 a.m. revealed one open vial of Lispro insulin with an expiration date of September 8, 2025. Observation of the Evergreen Medication Cart on September 9, 2025, at 11:25 a.m. revealed an open and undated container of Dorzolamide eye drops. Observation of the Birch Medication Cart 1 on September 9, 2025, at 11:32 a.m. revealed a vial of Lispro insulin with an open date of August 2, 2025, and no expiration date. This medication expired on August 29, 2025. Further observation of the Birch Medication Cart revealed an open container of Latanoprost eye drops with no open and no expiration date. The above information was conveyed to the Nursing Home Administrator on September 10, 2025, at 1:00 p.m. 28 Pa. Code 211.12(c)(d)(3) Nursing Services Previously cited 9/25/2024, 11/10/2024

Plan of Correction - To be completed: 10/08/2025

The eye drops and insulin on Chestnut med cart 2, Evergreen med cart and Birch medication cart 1 were discarded.

To identify potential affected residents. DON/designee completed an audit of facility med carts to ensure eye drops and insulin are dated when opened.

To prevent this from happening again DON/designee will in-service licensed staff on dating eye drops and insulin when opened.

To monitor and maintain compliance DON/designee will complete random eye drop and insulin audits to ensure labeling is completed when medication is opened weekly x4. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations as needed.

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

§483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

§483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Observations: Number of residents sampled:Number of residents cited: Based upon interview and clinical record review, it was determined that the facility failed to ensure appropriate notification was provided to a resident prior to a room change for one of twenty-five residents reviewed (Resident 16). Findings include: Review of Resident 16s diagnosis list revealed diagnoses including major depressive disorder (major loss of interest in pleasurable activities, characterized by changes in sleep patterns, appetite and/or daily routine), diabetes mellitus (failure of the body to produce insulin to enable sugar to pass through the bloodstream to cells for nourishment), and bladder cancer. Review of Resident 16s progress notes revealed that Resident 16 was sent to the hospital on August 11, 2025, related to abdominal pain. Further review of Resident 16s progress notes dated August 14, 2025, revealed resident arrived from hospital via stretcher with 2 attendants and taken to room 206 for admission, upon seeing [residents] room had been changed, [resident] began hollering that [resident] was not going into that room. Resident continued to scream, reorienting to the situation as this is the room given [resident] in the admission process, [resident] continued to scream, reminded [resident] choice was to accept the room or return to the hospital [resident] stated, take me back; attendants exited building with [resident] on the stretcher to return to hospital. Interview with Resident 16 on September 8, 2025, at 1:00 p.m. revealed Resident 16 was not informed of his room change prior to the room change. This interview further revealed that Resident 16s room was changed while Resident 16 was a patient in the hospital. Interview with the Nursing Home Administrator on September 9, 2025, at 11:00 a.m. confirmed that Resident 16s room was changed while Resident 16 was in the hospital. The interview further confirmed that Resident 16 was not notified of the room change prior to the facility assigning the resident to a different room. 28 Pa. Code 201.18(b)(1)(2) Management Previously cited 9/25/2024 28 Pa. Code 201.29(a)(b)(c) Resident Rights Previously cited 9/25/2024

Plan of Correction - To be completed: 10/08/2025

Facility unable to correct deficiency retroactively to resident R16.

To identify potential affected residents NHA/Designee will complete a 14 day look back of room/bed changes to ensure resident and RP were given appropriate notification.

To prevent this from happening again NHA/designee will re-educate/in-service administrative nursing staff and social worker on appropriate notification of room/bed changes.

To monitor and maintain compliance NHA/designee will randomly audit room/bed changes weekly x4. To ensure appropriate notification was provided to resident and RP. The results of the audits will be forwarded to facility QAPI committee for further review and recommendations as needed.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations: Number of residents sampled:Number of residents cited: Based on facility policy and procedure review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow physician orders and appropriately monitor fluid intake for one of one resident reviewed (Resident 3) Findings include: Review of the facility policy titled Encourage and Restricting Fluids (2001) states: Licensed staff will document on the eMAR (electronic medication administration record) yes or no if the fluid restriction is accepted or not accepted by the resident. Clinical medical record review for Resident 3 identified an active physicians order, dated March 17, 2025, for a 1500 ml (milliliter) fluid restriction. The order specified the following distribution: 7 a.m.3 p.m. nursing: 330 ml; 3 p.m.11 p.m. nursing: 330 ml; 11 p.m.7 a.m. nursing: 120 ml. Dietary allocations were as follows: breakfast 360 ml, lunch 240 ml, and dinner 120 ml, for a total of 1500 ml within a 24-hour period. Review of the clinical medical record further identified the following diagnoses: acute on chronic diastolic congestive heart failure (a medical condition where the heart cannot pump blood effectively, causing fluid buildup in the lungs and other parts of the body), end-stage renal disease (ESRD, final stage of chronic kidney disease where the kidneys can no longer function well enough to meet the bodys needs), and type 2 diabetes mellitus with hyperglycemia (The body does not use insulin properly and/or does not make enough insulin, leading to high blood sugar). Review of Resident R3s August MAR documented staff entries indicating yes or no to reflect whether Resident R3 was compliant with the prescribed fluid restriction. An interview with Licensed Practical Nurse (LPN) E3, conducted on September 10, 2025, at approximately 11:46 a.m., revealed that staff are instructed to document only yes or no regarding compliance with the fluid restriction, without recording the actual amount of fluid consumed. LPN E3 stated, By looking at the MAR you are not able to tell if Resident R3 is consuming 500 ml a day or 1500 ml a day, only that they are not going over 1500 ml over a 24-hour period. An interview with the Registered Dietitian (RD), conducted on September 10, 2025, at approximately 12:24 p.m., revealed that the RD is unable to accurately assess Resident R3s actual fluid intake due to the limitations of the facilitys documentation practices. An interview conducted on September 10, 2025, at 1:32 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the above findings. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 10/08/2025

Resident R3 continues on fluid restriction per physician orders.

To identify potential affected residents' DON/designees will complete an audit of current residents on fluid restrictions to ensure residents are receiving the fluid restriction per physician orders.

To prevent this from happening again current fluid restriction orders will be visible on the electronic MAR for licensed staff to view. The licensed staff will be in serviced on the electronic MAR orders and the proper way to document fluid restriction on the electronic MAR.

To monitor and maintain compliance the DON/designee will complete random audits on residents who are on fluid restrictions to ensure they are receiving the correct fluid amount weekly x 4. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations as needed.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations: Based on observation, it was determined that the facility failed to ensure that privacy curtains were clean on one of five units (Dogwood unit). Findings include: The facility failed to ensure a clean and homelike environment by not ensuring privacy curtains were clean when visibly soiled. Observations made on September 7, 2025, at 12:15 p.m., of 12 rooms on the Dogwood unit, revealed that nine of the residents rooms had privacy curtains that were stained with brown and/or red substances, the rooms of Resident 7, Resident 22, Resident 47, Resident 50, Resident 53, Resident 54, Resident 56, Resident 59, Resident 68, Resident 78, Resident 88, Resident 94, Resident 108, Resident 112, Resident 121, and Resident 123. During an interview on September 9, 2025, at approximately 1:30 p.m., when the above was presented the Nursing Home Administrator (NHA) stated she would investigate the matter. During phone interview on September 15, 2025, at 10:20 am, the Director of Nursing (DON) stated housekeeping usually cleans the privacy curtains upon discharge of a resident or when notified the curtains are visibly soiled. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) (e)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility

Plan of Correction - To be completed: 10/08/2025

Privacy curtains for rooms of the following residents on Dogwood unit R7, R22, R47, R50, R53, R54, R56, R59, R68, R78, R88, R94, R108, R112, R121 and R123 were cleaned and/or replaced.

To identify potential affected residents NHA/designee will audit the privacy curtains in the remaining rooms on Dogwood units to ensure cleanliness and notify housekeeping if cleaning is required.

To prevent this from happening again NHA/designee will re-educate/in-service housekeeping staff to inspect privacy curtains when cleaning resident rooms and either clean or replace as needed.

To monitor and maintain compliance NHA/designee will randomly audit resident rooms to ensure privacy curtains are clean weekly x4. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations as needed.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations: Number of residents sampled:Number of residents cited: Based on review of facility records and interview with staff, it was determined that the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to the resident or resident's representative when Medicare services ended for two of two residents (Residents 7 and 72). Findings include: Review of facility documentation revealed that Resident 7's last covered day of Medicare Part A services was July 11, 2025. Review of the SNF beneficiary Protection Notification Review revealed that the SNF ABN form was not provided. Documentation indicated "we sent it to the family by mail. Never got it back". The facility was unable to provide any further documentation to indicate that the resident or resident's representative was made aware of potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Review of facility documentation revealed that Resident 72's last covered day of Medicare Part A services was July 24, 2025. Review of the SNF beneficiary Protection Notification Review revealed that the SNF ABN form was not provided. Documentation indicated "we sent it to the family by mail. Never got it back". The facility was unable to provide any further documentation to indicate that the resident or resident's representative was made aware of potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Interview with the Nursing Home Administrator on September 10, 2025, at 12:48 p.m. confirmed that there was no evidence that Residents 2 and 72 were provided with the SNF ABN. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 7/22/25, 9/25/24 28 Pa. Code 201.18(b)(2)(3) Management Previously cited 9/25/24

Plan of Correction - To be completed: 10/08/2025

Facility unable to correct deficiency retroactively to resident 7 as they no longer reside in the facility, resident 72 received a SNF ABN.

To identify potential affected residents NHA/designee will complete a 14 day look back of residents issued a last covered day notice of Medicare A services to ensure a SNF ABN was provided to residents that did not discharge from the facility when Medicare A services ended.

To prevent this from happening again NHA/designee will re-educate/in-service the social worker, business office manager and director of rehab on issuing and documenting SNF ABNs with last covered day notice of Medicare A services.

To monitor and maintain compliance NHA/designee will randomly audit residents issued last covered day notice of Medicare A services weekly x4 to ensure SNF ABN was provided to residents that remained in the facility after Medicare A services ended. The results will be forwarded to facility QAPI committee for further review and recommendations as needed.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:

(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations: Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed document the disposition of medications upon discharge for one of three residents reviewed (Resident 126). Findings include: Review of facility policy, "Discharge Medications", revised March 2022, indicated that the nurse shall complete the medication disposition record, including but not limited to the resident's name, the name of each medication, and the quantity of each medication. The nursing staff shall forward the completed drug disposition records to medical records. Review of Resident 126's clinical record revealed that Resident 126 expired at the facility on June 23, 2025. Further review of the clinical record revealed no documentation of the disposition of the resident's medications. Interview with the Nursing Home Administrator on September 10, 2025, at 9:13 a.m. confirmed that there was no documentation of Resident 126's medication disposition.

Plan of Correction - To be completed: 10/08/2025

Resident R126 no longer resides in the facility.

No other residents were affected.

To prevent this from happening again DON/designee will in-service the licensed staff on the medication disposition UDA and when to be completed.

To monitor and maintain compliance the DON/designee will randomly audit residents who have been discharged to ensure medications are counted and UDA completed weekly x4. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations as needed.

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