Cycle 1
Health 2024-11-26 · Fire 2024-11-26
15 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Newark, DE
Encore At West Meadow
4-star overall rating with 2-star inspections with $16,448 in total fines with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
255 Possum Park Road, Newark, DE
(302) 366-0160
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-03-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.97
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
4.56
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.16
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,928
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9950
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.14
Baseline 17.43% · Performance 19.05% · Measure score 5.14 · Achievement 5.14 · Improvement 0
Healthcare-associated infections
0
Baseline 5.38% · Performance 9.09% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.44
Performance 49.63% · Measure score 3.44 · Achievement 3.44 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
8.26
Baseline 4.72 hours · Performance 5.43 hours · Measure score 8.26 · Achievement 8.26 · Improvement 6.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.74% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 279 · Observed rate 9.68% · Lower 95% interval 7.71% |
| Discharge to community | 61.35% |
50.57%
10.8 pts better
|
Better than the National Rate · Eligible stays 260 · Observed rate 55.38% · Lower 95% interval 54.64% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 90.8% |
95.27%
4.5 pts worse
|
Numerator 227 · Denominator 250 |
| Falls with major injury | 0.8% |
0.77%
About the same
|
Numerator 2 · Denominator 250 |
| Discharge self-care score | 53.03% |
53.69%
0.7 pts worse
|
Numerator 105 · Denominator 198 |
| Discharge mobility score | 50.51% |
50.94%
0.4 pts worse
|
Numerator 100 · Denominator 198 |
| Pressure ulcers or injuries, new or worsened | 2.8% |
2.29%
0.5 pts worse
|
Numerator 7 · Denominator 250 · Adjusted rate 2.6% |
| Healthcare-associated infections requiring hospitalization | 9.09% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 212 · Observed rate 9.91% · Lower 95% interval 6.35% |
| Staff COVID-19 vaccination coverage | 2.2% |
8.2%
6 pts worse
|
Numerator 5 · Denominator 227 |
| Staff flu vaccination coverage | 26.89% |
42%
15.1 pts worse
|
Numerator 64 · Denominator 238 |
| Discharge function score | 47.98% |
56.45%
8.5 pts worse
|
Numerator 95 · Denominator 198 |
| Transfer of health information to provider | 97.83% |
95.95%
1.9 pts better
|
Numerator 45 · Denominator 46 |
| Transfer of health information to patient | 99.35% |
96.28%
3.1 pts better
|
Numerator 154 · Denominator 155 |
| Resident COVID-19 vaccinations up to date | 33.09% |
25.2%
7.9 pts better
|
Numerator 45 · Denominator 136 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.4
0.8 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.4%
2.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.2%
1.5 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 1.6% · Q4 1.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.6%
2.3 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 9.6% · Q3 3.8% · Q4 6.4% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
21.1%
6.7 pts better
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 13.0% · Q3 14.8% · Q4 14.6% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
12.0%
2.5 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 7.9% · Q3 9.5% · Q4 5.0% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.1% |
17.5%
5.6 pts worse
|
16.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 34.1% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.6% |
14.7%
1.9 pts worse
|
14.9%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 28.3% · Q3 14.9% · Q4 12.5% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.7%
1.7 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 3.7% · Q4 2.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.0%
0.2 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 0.0% · Q4 5.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
21.6%
3 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 24.1% · Q3 20.7% · Q4 18.7% · 4Q avg 24.6% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.4%
0.2 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.7% · Q3 5.8% · Q4 5.9% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
83.5%
14.8 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.2% · Q3 97.4% · Q4 97.8% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
11.2%
1 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.6% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
0.9%
0.2 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.3% · Q3 0.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
83.1%
16 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.7% |
21.5%
4.8 pts better
|
23.9%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 16.5% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-03-31 · Fire 2021-03-31
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-26
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-04-01
E · Potential for more than minimal harm
2024-11-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-01
E · Potential for more than minimal harm
2024-11-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-01
E · Potential for more than minimal harm
2024-11-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-01
E · Potential for more than minimal harm
2024-11-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-01
Inspection history
Recent health citations
G · Actual harm
2025-10-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-10-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-28
D · Potential for more than minimal harm
2025-10-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-11-28
F · Potential for more than minimal harm
2024-11-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-11-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-23
J · Immediate jeopardy
2024-08-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-08-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-08-28
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-08-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-07
B · Minimal harm
2024-08-28
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-10-07
F · Potential for more than minimal harm
2023-10-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-04-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-26
F · Potential for more than minimal harm
2021-03-31
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-03-31
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-03-31
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-03-31
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-03-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-03-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-03-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-03-31
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-05-28
Penalties and ownership
What sits behind the stars
$16,448
2024-08-28
Fine
Fine · fine $16,448
Fine
Ownership
Nearby options
Other facilities in reach
#1
Newark Manor Nursing Home
Newark, DE
2-star overall rating with 2-star inspections with abuse icon flag with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Pike Creek Nursing & Rehabilitation Center
Wilmington, DE
1-star overall rating with 1-star inspections with Special Focus status with $484,596 in total fines with 30 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Jeanne Jugan Residence
Newark, DE
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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