Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Waters Of New Castle, The during CMS and state inspections, most recent first.
A resident with a left BKA, ESRD on dialysis, and high fall risk was care planned for mechanical lift transfers requiring two staff. Despite this, a CNA performed a mechanical lift transfer alone, stating she believed others were busy and wanted to get the resident up for breakfast before dialysis. During the transfer, the resident leaned forward, slid out of the sling, and fell headfirst to the floor, sustaining a forehead laceration requiring stitches and later being found to have an acute comminuted angulated distal femur fracture above the knee. A nurse responding to the incident found the resident on the floor with profuse bleeding from the forehead, and subsequent observations documented facial bruising, a hip bruise, and an above-knee immobilizer on the affected leg.
Two residents received each other’s bedtime medications after an RN set up their medications in cups and mixed them up, despite one resident questioning the unusually high number of pills. One resident with diabetes, chronic kidney disease, and vascular disease received multiple psych, GI, and other medications instead of his ordered carvedilol, fenofibrate, gabapentin, and oxycodone, while the other resident with cerebral palsy, dementia, and psychiatric diagnoses received those medications instead of his ordered regimen. The facility’s medication administration policy, which required verifying orders, checking labels and doses against the MAR, and confirming resident identity, was not effectively followed, resulting in this significant medication error.
Call Lights Not Kept Within Reach: Two residents were observed with call lights out of reach, including one whose touch pad was hanging behind the bed and another whose call light was on the floor behind the bed. Both residents had care plans directing staff to keep the call light in reach, and one resident stated this was not the first time she could not find her call light.
Failure to Provide Ordered Humidified Oxygen: A resident with COPD and asthma had an order for O2 via NC with a humidifier bottle changed weekly, but observations found the oxygen in use without humidification attached. Staff later verified the omission and applied the humidifier bottle after it was noted by the resident and QMA.
A resident admitted after left hip fracture surgery was ordered tramadol 50 mg every 6 hours PRN for pain, but staff did not make the medication available because the prescription was invalid and not signed. The resident reported being without tramadol since admission, said Tylenol did not help, and stated the lack of pain medication made it harder to walk with his walker. The DON confirmed tramadol was available in the ADC, but the nurse did not escalate the issue to obtain a valid signature.
Failure to monitor valproic acid levels for a resident receiving Divalproex Sodium for seizure control. The resident had epilepsy, CKD, and moderate cognitive impairment, and the EHR showed no valproic acid levels had been drawn or monitored since the prior year. The DON could not find recent lab documentation, and the NP stated there had been no order for routine valproic acid monitoring until the issue was brought to her attention.
The facility failed to accurately code MDS assessments for a resident receiving antipsychotic medication, despite clinical records indicating the use of Zyprexa. Interviews confirmed the coding errors, and the facility lacked a specific policy for the MDS assessment process.
Unsafe Mechanical Lift Transfer Resulting in Head Laceration and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a mechanical lift in accordance with the resident’s care plan and facility/mechanical lift guidelines. The resident had multiple significant medical conditions, including a left below-knee amputation, end-stage renal disease requiring dialysis, and an acute comminuted angulated fracture above the left knee diagnosed later. The resident’s care plan, initiated earlier in the year, specified that transfers required the use of a mechanical lift with two staff members assisting. A fall assessment identified the resident as high risk for falls, and the MDS indicated the resident was cognitively intact for daily decision-making and dependent on staff for transfers. On the date of the incident, progress notes documented that the resident was found lying on the floor on her back after reporting that she slid forward out of the mechanical lift. An emergency department note recorded that the resident was dropped headfirst from a mechanical lift at the facility and complained of head, neck, and back pain. The resident had a 3.0 cm laceration with indentation to the left frontal scalp, which required repair with five stitches. CT scans of the head and spine were negative for acute intracranial abnormality or spine fracture. A nurse who responded to the incident reported hearing a loud noise, finding the resident on her left side with a large gash to the forehead, and observing profuse bleeding that did not stop with applied pressure. Staff interviews and documentation confirmed that the transfer was performed by a single CNA, contrary to the resident’s care plan and facility guidelines requiring two staff for mechanical lift use. The CNA stated she hooked all four straps to the lift and began the transfer alone because she thought everyone was busy and wanted to get the resident up for breakfast before dialysis; she reported that the resident leaned forward and fell out of the sling onto her face. The CNA acknowledged she had been trained that two staff were required when using a mechanical lift. Subsequent documentation showed that the resident later complained of left leg pain during dialysis and was sent to the emergency room, where imaging revealed an acute comminuted angulated fracture involving the distal femoral metaphysis of the left leg. Observations days later noted a scabbed forehead laceration, facial bruising, a large pink bruise on the left hip, and an above-knee immobilizer on the left leg.
Medication Cup Mix-Up Leads to Two Residents Receiving Each Other’s Bedtime Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors when two residents received each other’s evening medications. On the evening in question, a nurse (RN 1) prepared bedtime medications for two residents whose rooms were next to each other and placed the medications into separate cups. RN 1 then mixed up the cups, resulting in each resident receiving the other’s prescribed bedtime medications. One resident, who was cognitively intact for daily decision making, questioned the number of pills because he did not usually take that many medications in the evening but proceeded to take them. One of the residents involved, Resident B, had diagnoses including diabetes, major depressive disorder, chronic kidney disease, and peripheral vascular disease. His bedtime medication orders included carvedilol 25 mg, fenofibrate 145 mg, gabapentin, and oxycodone 10 mg. Instead of these medications, he was administered Tylenol 500 mg two tablets, baclofen 10 mg, clonazepam 0.5 mg, ferrous sulfate 325 mg, florastor 250 mg, guaifenesin 200 mg, remeron 15 mg, pantoprazole, tamsulosin, and geodon 60 mg. The following morning, he reported to the DON, with a family member present, that he had received another resident’s medications and stated he felt very tired and sleepy. The other resident, Resident C, had diagnoses including borderline personality, cerebral palsy, anxiety, psychotic disorder, dementia, and muscle weakness, and was severely impaired for daily decision making. He was allergic to haldol and prozac. His bedtime medication orders included Tylenol 500 mg two tablets, baclofen 10 mg, clonazepam 0.5 mg, ferrous sulfate 325 mg, florastor 250 mg, guaifenesin 200 mg, remeron 15 mg, pantoprazole, tamsulosin, and geodon 60 mg. Instead, he was administered carvedilol 25 mg, fenofibrate 145 mg, gabapentin, and oxycodone 10 mg. The DON, Medical Director, and Nurse Practitioner were notified that the residents had received each other’s medications. The facility’s own medication administration policy required verifying a physician’s order, checking the medication label and dose against the MAR, and confirming the resident’s identity, but these steps were not effectively followed, resulting in the medication error.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for 2 residents reviewed for accommodation of needs. During an observation on 1/13/26 at 11:01 a.m., Resident 14 was sitting in a geriatric chair in her room, and her touch pad call light was hanging on the wall behind her bed, not within reach. The roommate’s call light was activated. During interview, the Staffing Coordinator stated that whoever brought Resident 14 back to her room was responsible for providing her call light, and then provided the resident with the touch pad call light. Resident 14’s record showed diagnoses including chronic heart failure, lack of coordination, unsteadiness on feet, COPD, major depressive disorder, and osteoarthritis. Her care plan directed staff to keep the call light in reach, and her annual MDS indicated she was severely impaired for daily decision making. During an observation and interview on 1/13/26 at 11:27 a.m., Resident 69 was lying in bed and stated she could not find her call light and requested help. Her call light was on the floor behind her bed, and she said this was not the first time she had been unable to find it. The roommate’s call light was activated, and CNA 3 entered the room and provided Resident 69 with her call light. Resident 69’s record showed diagnoses including respiratory failure, chronic kidney disease, weakness, heart failure, difficulty walking, diabetes, anxiety, and unsteadiness on feet. Her care plan identified her as at risk for falls due to weakness and directed staff to keep the call light in reach, and her quarterly MDS indicated she was cognitively intact and consistent and reasonable.
Failure to Provide Ordered Humidified Oxygen
Penalty
Summary
The facility failed to follow a physician’s order for humidified oxygen for Resident 13, who had diagnoses including COPD, mild intermittent asthma, and anxiety and was cognitively intact. The resident had an order dated 1/7/26 for oxygen at 1 to 2 L/min via nasal cannula as needed for shortness of breath and to change the humidifier bottle once weekly on Tuesday during the day shift and as needed. During observation on 1/13/26, the resident was on oxygen at 1 L/min with no humidified oxygen hooked up to the oxygen tank, despite the resident stating they used oxygen at home. On 1/14/26, another observation again found no humidity bottle attached to the oxygen tank. QMA 2 verified that no humidity was applied and then applied the humidity bottle to the oxygen tank. The resident did not refuse the humidified oxygen and later stated they had it on their oxygen tank at home and wondered why it was not on in the facility. The January 2026 MAR indicated the humidifier bottle was changed on 1/13/26, and the care plan identified the resident as at risk for respiratory distress related to asthma and COPD and included administering oxygen per physician order.
Pain Medication Not Available as Ordered
Penalty
Summary
The facility failed to ensure a newly admitted resident had his tramadol pain medication available as ordered by the physician. The resident, who had diagnoses including orthopedic aftercare, left fracture, diabetes, hypertension, contracture of the left hand, and osteoarthritis, had been admitted after a left hip fracture and open reduction and internal fixation surgery. The physician’s order dated 1/10/26 specified tramadol 50 mg every 6 hours as needed for pain, and the care plan identified the resident as at increased risk for pain/discomfort with an intervention to administer pain medication as ordered. During interviews, the resident stated he had been without tramadol since admission and that staff told him it had something to do with the prescription not being signed. He reported Tylenol did not help and that the lack of tramadol prevented him from walking with his walker and slowed him down. The DON stated the facility had tramadol available in the automated dispensing cabinet, but the resident was admitted with an invalid tramadol prescription. Staff attempted to contact an after-hours company twice for a correct prescription without success, the NP did not yet have authority to sign prescriptions, and the nurse did not contact the DON or Administrator to have the Medical Director sign the prescription. The DON learned of the situation later and obtained the prescription signature.
Failure to Monitor Valproic Acid Levels
Penalty
Summary
The facility failed to monitor valproic acid levels for a resident with epilepsy who was receiving Divalproex Sodium 500 mg twice daily for seizure management. The resident’s diagnoses included epilepsy, muscle weakness, and chronic kidney disease, and the annual MDS indicated moderate cognitive impairment, seizure disorder, and use of anticonvulsants. The resident’s care plan identified seizure activity risk and included administering medication as directed and following pharmaceutical recommendations and medication levels as ordered by the physician. Review of the resident’s EHR showed no valproic acid levels had been drawn or monitored since January 2025. The DON stated they could not find documentation of valproic acid levels drawn in the last year, and the NP stated there had been no order for a valproic acid level since taking over care in May 2025 and that routine monitoring was standard practice. The NP later entered orders for valproic acid levels every six months ongoing. The facility policies stated that medications should be periodically re-evaluated and that antiepileptic medication blood levels should be monitored periodically.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately code two Minimum Data Set (MDS) assessments for a resident who was receiving antipsychotic medication. The resident, who had diagnoses including anxiety, depression, nightmare disorder, and suicidal ideation, was documented in the MDS assessment as not receiving antipsychotic medications, despite clinical records indicating otherwise. Specifically, the resident's quarterly MDS assessment and prior annual MDS assessment both incorrectly reflected that the resident did not receive antipsychotic medications, which impacted the documentation of gradual drug reduction information for this type of medication. Interviews with the MDS Coordinator and the Executive Director confirmed the coding errors. The MDS Coordinator acknowledged that the resident had received Zyprexa, an antipsychotic medication, during the look-back periods for both MDS assessments. The Executive Director indicated that the facility did not have a specific policy or procedure related to the MDS assessment process and relied on the current Resident Assessment Instrument (RAI) Manual for guidance. The review of the resident's medication administration records corroborated that the resident had been administered Zyprexa during the relevant periods, highlighting the discrepancy in the MDS coding.
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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 |
| Hickory Creek At New Castle | 0.2 mi | ★★★★★ | 9 | 0 |
| Willows Of New Castle | 0.2 mi | ★★★★★ | 10 | 0 |
| Glen Oaks Health Campus | 3.2 mi | ★★★★★ | 11 | 0 |
| Middletown Nursing And Rehabilitation Center | 12.1 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.