F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did
not ensure physician was notified of change in resident's condition/status. Based on review of clinical
record, facility policy, and staff interviews, it was determined that the facility failed to notify the physician of a
change in condition/status for one of three residents reviewed (Resident R1). Findings include:Review of
facility policy titled Change in a Resident's Condition or Status, revised 2021, revealed the facility notifies
the resident, his or her attending physician, and the resident representative of changes in the resident's
medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights,
etc.). The nurse will notify the resident's attending physician or physician on call when there has been
a(an):a. accident or incident involving the resident;b. discovery of injuries of an unknown source;c. adverse
reaction to medication;d. significant change in the resident's physical/emotional/mental condition;e. need to
alter the resident's medical treatment significantly;f. refusal of treatment or medications two (2) or more
consecutive times);g. need to transfer the resident to a hospital/treatment center;h. discharge without
proper medical authority; and/[NAME]. specific instruction to notify the physician of changes in the
resident's condition.Clinical record review revealed Resident R1 was admitted to the facility on [DATE] with
a diagnosis that included severe protein calorie malnutrition (inadequate intake of essential nutrients,
particularly protein and calories), epilepsy (brain condition that causes reoccurring seizures), and
dysarthria (slurred speech). Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated
assessment of a resident's abilities and care needs), dated May 13, 2025, revealed the resident had a Brief
Interview for Mental Status (BIMS) score of 8 indicating moderately impaired cognition.Interview on July 18,
2025 at 12:05 p.m. with Employee E2, Licensed Practical Nurse, revealed he/she identified Resident R1
had increased slurred speech on the evening of July 17, 2025. Employee E2 confirmed he/she did not
notify the physician or document his/her observation due to relating the slurred speech to Resident R1's
previous respiratory illness he/she was recovering from since May 2025. Review of Resident R1's clinical
record from the months of May 2025 through June 2025 revealed no progress note on slurred speech or
worsening slurred speech related to respiratory illness. Interview on July 18, 2025 at 11:55 a.m. with
Employee E1, Nurse Practitioner, confirmed when resident has change in condition/status for example
slurred speech, staff is expected to document and notify physician. Review of Resident R1's nursing
progress note, dated June 16, 2025 at 6:18 p.m., stated resident relative here and concerned as she has
seen a dramatic negative change in him since Thursday. Noted by this nursing supervisor a dramatic
change in vocal ability. His voice sounds as if his tongue is too big. Was able to follow conversation and was
able to change an answer to a question from narrative to yes/no answer when asked about going to
hospital for further evaluation. Relative getting guidance from wife. She has confirmed desire for him to be
seen. Call out to on-call for confirmation. Review of Resident R1's nursing progress note, dated June
(continued on next page)
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
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
395403
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395403
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Newport Meadows Health and Rehabilitation Center
41 Newport Avenue
Christiana, PA 17509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
16, 2025 at 6:25 p.m., revealed Resident R1 was transferred to hospital for evaluation.Review of Resident
R1's hospital record, dated June 17, 2025, revealed Resident R1 presented with worsening dysarthria, left
sided chest pain and left shoulder pain. Patient was found to have elevated Dilantin level of 29.5. Exam
notable for confusion, bilateral lower extremity weakness, and severe dysarthria. Further review of Resident
R1's hospital record, dated June 18, 2025, stated the patient was found to be less responsive than normal
yesterday with worsening slurred speech. Personally called [NAME] Meadows and spoke with Nursing
Supervisor who stated she was informed that the patient had a steady decline in his speech over the
weekend and when a visitor came to see the patient yesterday (Monday) the visitor thought the speech
changes were more pronounced. Resident R1's hospital records revealed Resident R1 was diagnosed with
Dilantin toxicity (prescription drug used to treat seizures, but it can cause severe toxicity if the dose is too
high or if it interacts with other drugs.The facility failed to notify the physician in a timely manner related to a
change in Resident R1's condition/status. Resident R1's family requested resident to be assessed, which
resulted in resident being transferred to hospital and diagnosed with Dilantin toxicity. 28 Pa. Code:
201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12
(d)(1) Nursing services.
Event ID:
Facility ID:
395403
If continuation sheet
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