Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hickory Creek At New Castle during CMS and state inspections, most recent first.
A resident was sexually abused by another resident when he entered her room and touched her breast over her clothing. The resident reported feeling uneasy and delayed telling staff, while the other resident admitted to touching her breast and said he had gone into her room to give candy. The ED substantiated the allegation as abuse.
Incomplete abuse investigation report: The facility failed to provide sufficient details in the abuse investigation report for two residents. A resident reported that another resident entered her room and touched her breast, and the other resident admitted to touching her breast. However, the follow-up report did not state that the allegation was substantiated or include key findings from the investigation and related care plan details.
Failure to Follow Fall-Prevention Care Plan: A resident with osteoporosis, Lennox-Gastaut syndrome, anxiety, severe cognitive impairment, and fall risk had a care plan requiring a helmet at all times and the bed in the lowest position. Staff observed the resident in bed without the helmet and with the bed not lowered, and interviews showed inconsistent understanding of when the helmet should be worn and whether it was used during an unwitnessed fall out of bed.
Respiratory equipment was not handled as ordered for two residents. One resident with COPD had a nebulizer mask left hanging uncovered and liquid still in the aerosol chamber, despite an order for routine nebulizer treatments and a policy requiring the unit to be disassembled and stored in a bag when not in use. Another resident with chronic respiratory failure and severe cognitive impairment had continuous O2, but the tubing was not dated and ear protectors were not in place during multiple observations, despite physician orders for both.
A resident with chronic back pain, disc degeneration, and spinal stenosis waited an extended period for an MRI required before a pain specialist appointment. The record showed the clinic requested the MRI and PT before the initial visit, but the facility did not timely complete the scheduling process, with the DON relying on a desk calendar entry that was not entered into the EHR and the hospital stating the MRI was only scheduled after the facility called in.
Failure to hold antihypertensive meds as ordered occurred when staff administered Amlodipine and Carvedilol to a resident with HTN despite BP readings below the ordered diastolic parameters. The MAR showed multiple doses were given when DBP was under 60, and the DON confirmed the meds should have been held per the physician's orders and facility policy.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents did not receive necessary behavioral health care: one did not receive a prescribed antipsychotic injection, and another experienced a behavioral outburst where staff failed to follow the care plan's outlined interventions, including maintaining a calm environment and individualized approaches.
Two residents engaged in a relationship involving physical affection, but the facility did not assess their ability to consent or develop individualized care plans addressing their relationship, despite one resident having moderate cognitive impairment and the other being cognitively intact. The required documentation and assessments were not found in their clinical records, contrary to facility policy.
The facility did not provide eight consecutive hours of RN coverage on two days during the review period, relying on PRN RNs and the DON for coverage under a staffing waiver. The facility lacked a specific policy for RN coverage and used mitigation strategies such as not admitting residents needing RN-specific care and arranging for on-call RN support.
Two residents who were cognitively intact and dependent on staff for toileting experienced significant delays in receiving incontinence care, resulting in prolonged exposure to urine and feelings of humiliation. One resident reported being left in soaked linens overnight, while another described waiting up to two hours for assistance and a persistent urine odor in her room. Staff interviews and observations confirmed these delays, and facility policy requires residents to be treated with dignity and respect.
Two residents did not have their care preferences accommodated: one, who required staff assistance and preferred showers, was frequently given bed baths instead, and another, who had a care plan for a pressure-reducing cushion in his wheelchair, was observed without the cushion and reported never using one. Staff did not consistently follow care plans or utilize available resources to meet these residents' needs.
A resident dependent on staff for toileting was left in a soiled brief for four hours after activating her call light, resulting in raw skin and moisture-associated dermatitis. The incident was witnessed by a roommate and reported to nursing staff. Observations and records confirmed the resident's ongoing need for assistance with ADLs and documented skin breakdown.
A resident with chronic respiratory failure and other conditions was observed using an electronic cigarette while receiving oxygen, despite facility policy prohibiting this practice. Staff provided inconsistent instructions, and the resident was unable to turn off the oxygen independently. The DON was aware of the situation, but the resident had not been educated or authorized to self-administer oxygen, resulting in a failure to prevent this accident hazard.
The facility failed to ensure RN coverage for at least eight consecutive hours a day, seven days a week for 14 of 31 days reviewed, potentially affecting 27 residents. The Director of Nursing confirmed the lack of required RN coverage and indicated no specific policy for RN coverage, relying on federal regulations instead.
The facility failed to develop and implement care plans for the utilization of specific medications for three residents, including those with acute and chronic respiratory failure, dementia, and GERD. This was identified through interviews and record reviews, revealing non-compliance with the facility's care plan policy.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. Resident B reported that Resident D entered her room, where the door was shut, and touched her breast over her clothing after bringing candy to the room. Resident B stated she felt uneasy about the incident and delayed reporting it for a couple of days. Her clinical record showed diagnoses including major depressive disorder and insomnia. The investigation documented that Resident B told the Executive Director that Resident D had come into her room and touched her chest inappropriately on top of clothing. In a separate interview, Resident D admitted that he touched Resident B's breast and stated that he went into her room, gave candy to her roommate and then to Resident B, and touched her when she stood up and hugged him. The Executive Director substantiated the allegation as abuse based on Resident D's admission. Resident D's record included diagnoses of depression and anxiety.
Incomplete abuse investigation report
Penalty
Summary
The facility failed to provide sufficient information to describe the results of an abuse investigation to the Indiana Department of Health for two residents reviewed for abuse. Resident B had diagnoses including major depressive disorder and insomnia, and Resident D had diagnoses including depression and anxiety. Resident B stated that Resident D entered her room, the door was shut, and he grabbed her breast while giving her candy. She said she felt uneasy about the incident and later told the Executive Director about it. The investigation documentation showed that the Executive Director interviewed Resident B and Resident D on 4/6/26. Resident B stated that Resident D had come into her room over a week earlier and touched her inappropriately on the breast through her clothing. Resident D admitted that he touched Resident B's breast on top of her clothing and said he did not mean any ill intent. The ED later stated she substantiated abuse because Resident D admitted to touching Resident B's breast. The follow-up section of the incident report, dated 4/11/26, stated only that staff and resident interviews were completed with no concerns noted, that Resident B showed no signs or symptoms of psychosocial distress, and that residents were seen by psych services. It did not state that Resident D admitted to touching Resident B's breast, that the allegation was substantiated, or that Resident D had care plan interventions related to the incident, including separation from the other resident during meals and activities, not entering other residents' rooms uninvited, and passing out candy only in common areas. The facility policy required a report of the investigation to be forwarded to the Indiana State Department of Health within 5 working days.
Failure to Follow Fall-Prevention Care Plan
Penalty
Summary
The facility failed to implement Resident 1’s comprehensive care plan interventions to prevent falls. Resident 1’s record showed diagnoses including osteoporosis, Lennox-Gastaut syndrome, and anxiety, and the Quarterly MDS dated 3/17/26 indicated severe cognitive impairment, no behaviors for rejecting care, non-traumatic brain dysfunction, and risk for falls. The care plan dated 9/10/24 identified a history of falls, unsteady gait, and altered awareness of the immediate physical environment, with interventions including the bed being in the lowest position and a helmet to be worn at all times, except for skin checks and hair washing. During observations on 5/26/26 and 5/27/26, Resident 1 was lying in bed without a helmet on and the bed was not in the lowest position. A progress note dated 11/19/25 documented an unwitnessed fall out of bed, but did not indicate that the helmet was on during or after the fall. In interviews, the ED stated they did not know whether Resident 1 had the helmet on when the fall occurred, while an LPN believed the helmet was only needed when the resident was out of bed and was unsure why it was not on in bed or why the bed was not in the lowest position. A CNA stated they usually removed the helmet when placing the resident in bed and put it back on when it was time to get out of bed.
Respiratory Equipment Not Stored or Maintained as Ordered
Penalty
Summary
Respiratory care was not provided as ordered for Resident 23, who had COPD, was cognitively intact, and received respiratory therapy daily. The care plan identified the resident as at risk for impaired gas exchange and included nebulizer treatments as ordered. A physician order directed nebulizer treatments three times daily. During observation, the nebulizer mask was hanging on the side of the compressor without covering, and later the nebulizer was observed with liquid still in the aerosol chamber. The facility policy provided by the Executive Direction stated the treatment should be administered until the medication in the chamber is depleted and the unit should be disassembled and stored in a bag when not in use. Respiratory equipment was also not maintained as ordered for Resident 1, who had chronic respiratory failure, heart failure, generalized anxiety disorder, and severe cognitive impairment, and received continuous oxygen. Physician orders directed oxygen tubing to be changed weekly and ear protectors to be applied to the oxygen tubing every shift. During multiple observations, the resident's oxygen tubing was not dated and the ear protectors were not in place. An LPN stated there was no date on the tubing to show when it had been changed and did not know why the ear protectors were not on. The ED stated nursing staff were responsible for ensuring the tubing was dated when changed and that the ear protectors were on as ordered.
Delayed MRI Scheduling for Pain Specialist Referral
Penalty
Summary
The facility failed to timely schedule an imaging appointment needed before a pain specialist visit for a resident with chronic back pain. The resident had diagnoses including intervertebral disc degeneration with lumbar discogenic back pain and lower extremity pain, and spinal stenosis. The quarterly MDS indicated the resident was cognitively intact, used a wheelchair, needed substantial to maximal assistance with transfers, and received scheduled pain medication. During interview, the resident stated their back had been hurting really bad and that they had been waiting a long time for the back scan required before seeing the pain specialist. The record showed a physician order to refer the resident to an interventional pain and spine clinic for chronic back pain, followed by a note that a message was left for the pain clinic. Later documentation stated the pain clinic requested an MRI and 6 weeks of PT before the initial appointment. The clinical team attempted to schedule the MRI and was awaiting hospital scheduling, while an LPN later stated the hospital said a referral order was needed before the MRI could be scheduled and that the nurse practitioner was notified. The DON stated the facility had sent the order to central scheduling and was waiting for a date and time, and also stated an appointment date was written on a desk calendar but was not entered into the EHR. Central scheduling stated the MRI was ultimately scheduled after the facility called in.
Failure to Hold Antihypertensive Medications for Low Blood Pressure
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met when the facility failed to hold a resident's antihypertensive medications as ordered based on blood pressure parameters. Resident 23 had diagnoses including hypertension, and the care plan for ineffective tissue perfusion directed staff to administer medications as ordered and monitor vital signs. The physician's orders for May 2026 directed staff to give Amlodipine 10 mg daily only if systolic blood pressure was at least 100 and diastolic blood pressure was at least 60, and to give Carvedilol 25 mg twice daily only if systolic blood pressure was at least 110 and diastolic blood pressure was at least 60. Review of the MAR showed Amlodipine was administered on multiple days when the resident's diastolic blood pressure was below 60, including readings of 54 and 59. Carvedilol was also administered on multiple occasions when the diastolic blood pressure was below 60, including readings of 54, 58, 59, 50, and 57. The DON reviewed the MAR and confirmed that Amlodipine and Carvedilol were administered on those dates when they should have been held. The facility policy stated staff should verify the correct medication, dose, route, rate, time, and resident, and obtain vital signs if necessary.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Administer Psychotropic Medication and Implement Behavioral Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents. For one resident with a history of stroke and behavioral disturbances, the facility did not administer a prescribed antipsychotic medication via intramuscular injection as ordered by the physician. The resident's care plan specifically included the intervention to administer medications as ordered, and the medication administration record confirmed the dose was missed. The psychiatric nurse practitioner expressed concern about the missed dose due to escalating behaviors observed in the resident. For another resident with diagnoses including depression, anxiety, pseudobulbar affect, and hemiplegia, the facility did not implement the behavioral care plan during an incident involving a staff member. The care plan outlined specific approaches for managing the resident's behavioral outbursts, such as maintaining a calm environment, approaching the resident calmly and individually, and providing reassurance. During the incident, the Maintenance Director and other staff entered the resident's room while the resident was upset, and the Maintenance Director engaged in a confrontational exchange, raising his voice and pointing at the resident. Multiple interviews confirmed that the staff did not follow the outlined behavioral interventions, and the situation escalated, causing distress to the resident. The facility's behavior management policy requires individualized, non-pharmacological interventions and staff education on resident-specific interventions. Despite this policy, the staff involved did not adhere to the prescribed approaches for managing behavioral expressions, resulting in a failure to provide the necessary behavioral health care and services as required.
Failure to Assess Consent and Develop Care Plans for Resident Relationships
Penalty
Summary
The facility failed to assess and document the ability of two residents to consent to a resident-to-resident relationship and did not establish individualized, resident-centered care plans addressing their relationship. Resident B, who had a history of stroke and behavioral disturbances and was assessed as having moderate cognitive impairment, reported being in a relationship with Resident C, which included holding hands, playing cards, and kissing. However, there was no documentation in Resident B's clinical record regarding an assessment of her ability to consent to this relationship or a care plan addressing her sexuality and relationship with Resident C. Similarly, Resident C, who had diagnoses including chronic obstructive pulmonary disease and depression and was assessed as cognitively intact, also reported being in a relationship with Resident B, which involved spending time together and kissing. The clinical record for Resident C also lacked documentation of an assessment of his ability to consent and a care plan for his sexuality and relationship with Resident B. The Executive Director confirmed that there was no documentation of capacity to consent or care plans for either resident, despite facility policy requiring such assessments and documentation.
Failure to Provide Consistent RN Coverage as Required
Penalty
Summary
The facility failed to provide eight consecutive hours of registered nurse (RN) coverage daily for two out of thirty days reviewed, as required by regulation. Review of the nursing schedule showed that there was no RN coverage on April 20 and May 3. The facility was operating under a nurse-staffing waiver for RN coverage and relied primarily on PRN RNs and the DON to meet coverage requirements, but this was not consistent enough to eliminate the need for the waiver. The Executive Director confirmed that there was no policy regarding RN coverage and that the facility's expectation was to follow federal regulations. At the time of the deficiency, the facility had implemented a mitigation strategy to not admit residents needing RN-specific care, to have an RN on-call, and to coordinate with a local facility for RN support if needed.
Failure to Ensure Timely Incontinence Care and Resident Dignity
Penalty
Summary
The facility failed to promote resident dignity by not ensuring timely incontinence care for two residents who were cognitively intact and dependent on staff for toileting. One resident, with diagnoses including chronic respiratory failure, epilepsy, and major depressive disorder, reported having to wait long periods at night to be changed after episodes of incontinence. She described being left in soaked linens until morning, which caused her frustration, anger, and humiliation. Observations confirmed her brief was wet during care, and her roommate corroborated that staff often delayed responding to call lights, sometimes turning them off and not returning promptly. The Director of Nursing acknowledged that the resident's bed was often soaked, attributing it to her medications, and stated that staff were expected to check every two hours. Another resident, with bilateral lower limb amputations and major depression, also required assistance with toileting and reported waiting up to two hours for help after activating her call light, particularly in the evenings. She described having to sit in urine for extended periods, leading to feelings of disgust and humiliation. Her room was noted to have a urine odor, and she stated that her room was not cleaned on weekends, contributing to the persistent smell. Facility policy indicated residents have the right to be treated with consideration, respect, and full recognition of their dignity.
Failure to Accommodate Resident Preferences for Showers and Pressure-Reducing Cushion
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents regarding their care routines. One resident, who had diagnoses including cerebral palsy, diabetes, cerebral infarction with hemiplegia and hemiparesis, anxiety, and major depressive disorder, was dependent on staff for showering and had a documented preference and care plan for showers three times a week. Despite this, records showed that the resident frequently received bed baths instead of showers on multiple scheduled days over two months, and the resident reported that only one CNA would provide showers while others gave bed baths due to the need for a mechanical lift. Another resident, with diagnoses of schizophrenia and chronic kidney disease, had a care plan indicating the need for a pressure-reducing cushion while in a wheelchair due to risk for skin breakdown. During observations, the resident was found both with and without the cushion in place, and stated he had never used a cushion in his wheelchair. The DON confirmed that the resident's cushion was unavailable at one point because it was drying after being washed, and that spare cushions were available but not used by staff. Facility policy required reasonable accommodation of resident needs and preferences.
Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for toileting and incontinent care reported being left in a soiled brief for four hours, despite activating her call light at 10:00 a.m. and not being changed until 2:00 p.m. The resident stated that her brief was wet with urine and contained a bowel movement during this period, and her roommate confirmed witnessing the incident. The resident reported the delay to both an LPN and a CNA, as well as other nursing staff. She also indicated that she had a clock in her room and timed the incident, and that her skin became raw as a result of prolonged exposure to the soiled brief. On a subsequent observation, the resident was again found with a soaked brief that had leaked through her clothing, and her buttocks were noted to be pink, shiny, and raw. The resident's medical record indicated diagnoses including urinary tract infection, multiple sclerosis, chronic kidney disease, morbid obesity, and neuromuscular dysfunction of the bladder, with a care plan requiring assistance with ADLs and incontinent care as needed. A recent skin assessment documented moisture-associated dermatitis, and a physician order was in place for application of a barrier cream to the buttocks every shift for redness. Facility policy and staff competency requirements included providing toileting or perineal care as needed.
Failure to Prevent Use of Electronic Cigarette While on Oxygen
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure, hypoxia, epilepsy, and schizoaffective disorder was observed using an electronic cigarette while receiving oxygen therapy. The resident was cognitively intact but dependent on assistance for mobility. Multiple observations and interviews confirmed that the resident regularly used an electronic cigarette while on oxygen, and staff provided inconsistent guidance regarding whether this was permitted. The resident reported being unable to turn off the oxygen herself due to its placement out of reach and stated that she had been using the electronic cigarette with oxygen for over two years without staff intervention until the survey. The facility's policy explicitly restricted the use of electronic cigarettes while oxygen was in use, requiring oxygen to be shut off and removed prior to use. The DON acknowledged awareness of the resident's actions and confirmed that the resident did not have an order to self-administer oxygen nor had she been educated to manage it. The care plan indicated that the electronic cigarette policy would be reviewed with the resident, but there was no evidence that effective supervision or policy enforcement occurred to prevent the resident from using the electronic cigarette while on oxygen.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure there was Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week for 14 of 31 days reviewed. This deficiency had the potential to affect 27 residents. The review of the schedule and RN time sheets from March 1, 2024, to April 1, 2024, indicated that eight hours of RN coverage were not completed on 14 specific dates. An interview with the Director of Nursing on April 4, 2024, confirmed that the required RN coverage was not provided on these dates. Additionally, the Director of Nursing indicated that there was no specific policy for RN coverage, but the facility would follow the federal regulation of RN coverage of at least eight consecutive hours a day, seven days a week.
Failure to Develop and Implement Medication Care Plans
Penalty
Summary
The facility failed to develop and implement care plans for the utilization of specific medications for three residents. Resident 7, who was cognitively intact and had a diagnosis of acute and chronic respiratory failure with hypoxia, did not have care plans for the utilization of oxybutynin and NicoDerm. Resident 13, who was moderately cognitively impaired with a progressive neurological condition, had a dementia care plan that did not include the utilization of donepezil and memantine, despite physician orders for these medications. Resident 14, who was cognitively intact and had a diagnosis of gastro-esophageal reflux disease (GERD), did not have care plans for the utilization and monitoring of ferrous sulfate, Jardiance, and omeprazole, despite physician orders for these medications. An interview with the Administration revealed that the MDS Coordinator had not developed care plans for the specified medications for Residents 7, 13, and 14. The facility's policy on IDT Comprehensive Care Plan Policy requires that care plans include measurable goals and resident-specific interventions based on the resident's needs and preferences to promote their highest level of functioning. However, this policy was not followed, leading to the deficiencies identified in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Castle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebrooke Rehabilitation Center | 0.1 mi | ★★★★★ | 3 | 0 |
| Waters Of New Castle, The | 0.2 mi | ★★★★★ | 8 | 0 |
| Willows Of New Castle | 0.2 mi | ★★★★★ | 10 | 0 |
| Glen Oaks Health Campus | 3 mi | ★★★★★ | 11 | 0 |
| Middletown Nursing And Rehabilitation Center | 12.2 mi | ★★★★★ | 10 | 0 |
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