Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 49
Capacity: 95
Deficiencies: 1
Jun 6, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/08/25 was conducted by the Indiana Department of Health.
Findings
At this PSR survey, Willows of New Castle was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinkled except for a detached wooden storage shed.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| HVAC heating, ventilation, and air conditioning shall comply with 9.2 and be installed in accordance with the manufacturer's specifications. This requirement is not met as evidenced by continuing annual waiver approved. | SS=F |
Report Facts
Facility capacity: 95
Census: 49
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Apr 8, 2025
Visit Reason
This visit was for the investigation of complaints IN00455915 and IN00457043, conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on March 14, 2025.
Findings
No deficiencies related to the allegations in complaints IN00455915 and IN00457043 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigations.
Complaint Details
Complaint IN00455915 and Complaint IN00457043 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 54
Total Capacity: 54
Medicare Census: 6
Medicaid Census: 30
Other Payor Census: 18
Inspection Report
Re-Inspection
Census: 54
Capacity: 54
Deficiencies: 0
Apr 8, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on March 14, 2025, conducted in conjunction with the Investigation of Complaints IN00455915 and IN00457043.
Findings
Willows of New Castle was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Complaint Details
Investigation of Complaints IN00455915 and IN00457043 was conducted in conjunction with this visit.
Report Facts
Census SNF/NF beds: 54
Census total residents: 54
Census Medicare residents: 6
Census Medicaid residents: 30
Census residents with other payor types: 18
Inspection Report
Life Safety
Census: 54
Capacity: 95
Deficiencies: 10
Apr 8, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 04/08/2025 to assess compliance with federal and state regulations including 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Multiple deficiencies were identified including obstructed means of egress, inadequate egress lighting, kitchen hood exhaust issues, fire extinguisher inspection lapses, corridor door impediments, unprotected smoke barrier penetrations, HVAC system issues, improper use of extension cords, and lack of documentation for electrical equipment testing.
Severity Breakdown
SS=E: 6
SS=D: 2
SS=F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 8 means of egress were continuously maintained free of obstructions; tables and chairs stored in corridor obstructed exit access. | SS=E |
| Failed to ensure egress lighting for 1 of 8 exit means was arranged so failure of any single lighting fixture would not leave area in darkness; one light bulb burnt out at main entrance lobby. | SS=E |
| Failed to ensure 1 of 1 kitchen range hood exhaust systems was maintained in proper working order; hinge kit missing and cooking appliances not returned to approved design location. | SS=D |
| Failed to ensure 1 of 20 portable fire extinguishers were inspected monthly with documented date and initials; missing documentation for 3 months. | SS=E |
| Failed to ensure 1 of 44 corridor doors to resident sleeping rooms had no impediment to closing and latching; door propped open with trash can. | SS=E |
| Failed to ensure 1 of 6 smoke barrier walls were protected to maintain fire resistance rating; unsealed annular space around sprinkler pipe and electrical conduits. | SS=E |
| Failed to ensure egress corridors were not used as a portion of a return air system serving adjoining rooms for all resident rooms and corridors; waiver requested. | SS=F |
| Failed to ensure means of egress in adjoining construction, repair and improvement operations comply with LSC; no daily inspection documentation for egress in construction area. | SS=E |
| Failed to ensure 1 of 1 extension cords were not used as a substitute for fixed wiring; brown extension cord used in resident room. | SS=D |
| Failed to conduct required maintenance and maintain complete documentation of inspections for all Patient Care Related Electrical Equipment (PCREE); no testing documentation available. | SS=F |
Report Facts
Deficiencies cited: 10
Residents potentially affected: 20
Facility capacity: 95
Census: 54
Fire extinguisher inspection missing months: 3
Resident rooms: 44
Egress corridors: 8
Estimated cost to fix HVAC deficiency: 250000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Patton | Executive Director | Signed the report. |
| Maintenance Director | Interviewed and involved in multiple findings and corrective actions related to means of egress, lighting, kitchen hood, fire extinguishers, corridor doors, smoke barriers, HVAC, construction egress, extension cords, and electrical equipment testing. | |
| Regional Director of Operations | Interviewed and involved in review of findings and corrective actions. | |
| Administrator | Interviewed and involved in review of findings and corrective actions. |
Inspection Report
Renewal
Census: 52
Capacity: 52
Deficiencies: 3
Mar 14, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 10 to March 14, 2025.
Findings
The facility was found deficient in several areas including failure to ensure residents were treated with dignity, failure to provide bathing as requested and care planned, and failure to provide routine dental care when an inside source was not available. Corrective actions and monitoring plans were outlined for each deficiency.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were treated with dignity during care for 2 of 3 residents reviewed. | SS=D |
| Facility failed to provide a bath and/or shower upon request and as care planned for 1 of 1 resident reviewed for bathing. | SS=D |
| Facility failed to provide routine dental care to residents when an inside source was not available for 1 of 3 residents reviewed for dental services. | SS=D |
Report Facts
Census: 52
Total Capacity: 52
Medicare Residents: 3
Medicaid Residents: 32
Other Payor Residents: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Patton | Executive Director | Named as facility representative and involved in corrective action oversight |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 2
Jan 9, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00449670 related to federal/state deficiencies concerning care for residents with Clostridium difficile infection and urinary tract infections.
Findings
The facility failed to ensure thorough and accurate assessments and documentation for residents diagnosed with Clostridium difficile infection and urinary tract infections. Deficiencies included incomplete infection control documentation, improper isolation procedures, and inadequate treatment and monitoring of UTIs.
Complaint Details
Complaint IN00449670 - Federal/state deficiencies related to the allegations are cited at F684 and F690.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents with Clostridium difficile infection received thorough and accurate assessments and documentation, including stooling status and isolation orders. | SS=D |
| Failed to ensure residents with urinary tract infections received prompt treatment, accurate review of urine culture and sensitivity reports, and thorough daily nursing assessments. | SS=D |
Report Facts
Census: 54
Total Capacity: 54
Medicare Census: 4
Medicaid Census: 33
Other Payor Census: 17
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Patton | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding deficiencies in infection control and UTI treatment |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 0
Aug 22, 2024
Visit Reason
This visit was for the investigation of Complaint IN00441064.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00441064 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 8
Medicaid census: 35
Other payor census: 14
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Jul 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429651 at Willows Of New Castle.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00429651 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 52
Census total residents: 52
Census Medicare residents: 4
Census Medicaid residents: 36
Census other payor residents: 12
Inspection Report
Life Safety
Census: 61
Capacity: 95
Deficiencies: 0
Apr 29, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Life Safety Code Recertification and State Licensure Survey conducted on 02/15/24 and a prior PSR on 03/20/24 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, The Willows of New Castle was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinkled except for a detached wooden storage shed.
Report Facts
Facility capacity: 95
Census: 61
Inspection Report
Re-Inspection
Census: 63
Capacity: 95
Deficiencies: 2
Mar 20, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted to verify correction of previous deficiencies.
Findings
The facility was found not in compliance with Life Safety Code requirements, including an uneven exit discharge surface and corridor doors that failed to latch properly and resist smoke passage. Corrective actions were planned and partially implemented, with ongoing monitoring to prevent recurrence.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Exit discharge near resident room 22 had a 2-inch uneven rise in the grade, failing to provide a level walking surface free of obstructions. | SS=E |
| Two corridor doors (Kitchen Serving Door and Kitchen Dry Storage room door) failed to self-close and latch, impeding smoke resistance. | SS=E |
Report Facts
Facility capacity: 95
Census: 63
Exit discharges inspected: 8
Corridor doors inspected: 20
Residents potentially affected by exit discharge deficiency: 15
Residents potentially affected by corridor door deficiency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelsey Meal | HFA | Signed the report |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Re-Inspection
Census: 62
Capacity: 62
Deficiencies: 0
Feb 22, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-01-29, including a PSR to the Investigation of Complaint IN00425076 completed on 2024-01-29.
Findings
Willows of New Castle was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00425076.
Complaint Details
Complaint IN00425076 was investigated and found to be corrected.
Report Facts
Census SNF/NF beds: 62
Census Medicare residents: 8
Census Medicaid residents: 43
Census Other residents: 11
Inspection Report
Life Safety
Census: 63
Capacity: 95
Deficiencies: 7
Feb 15, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 02/15/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to fire safety, egress doors, exit discharge surfaces, hazardous area doors, corridor doors, and HVAC system use of egress corridors as return air systems.
Severity Breakdown
SS=E: 6
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Laundry area dryer room was not free of lint and other debris. | SS=E |
| Means of egress for 1 of over 8 exit doors was not readily accessible; exit door near resident room #46 was magnetically locked without posted code. | SS=E |
| 2 of 8 exit discharges had uneven or obstructed walking surfaces. | SS=E |
| 1 of over 10 hazardous area doors (Activities Director's office) lacked a properly working self-closing device. | SS=E |
| Hazardous area (Southeast Lounge) was open to corridor and used as storage with combustible items. | SS=E |
| 4 of over 20 corridor doors failed to latch positively and resist passage of smoke. | SS=E |
| Egress corridors were used as a portion of a return air system serving adjoining rooms for all resident rooms and corridors. | SS=F |
Report Facts
Facility capacity: 95
Census: 63
Exit doors: 8
Hazardous area doors: 10
Corridor doors: 20
Resident rooms: 84
Corridors: 8
Estimated cost: 72150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelsey Meal | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 11
Jan 29, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00425076.
Findings
The facility was found deficient in multiple areas including failure to complete self-administration assessments, failure to provide fresh water daily, failure to honor resident preferences, failure to maintain a safe and clean environment, inaccurate MDS assessments, incomplete care plans, failure to complete weekly nursing assessments, unsafe bed rail dimensions, and incomplete incident reporting.
Complaint Details
Complaint IN00425076 was investigated and federal/state deficiencies related to the allegations were cited at F-689 and F-9999.
Severity Breakdown
SS=D: 10
SS=G: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to complete self-administration assessment for a resident self-administering nasal spray. | SS=D |
| Failure to provide fresh water daily for 2 of 5 residents reviewed for hydration. | SS=D |
| Failure to provide a resident with her choice and preference for bedtime. | SS=D |
| Failure to promote a clean environment for a resident by having dried fecal matter on toilet and dried brown substance on bed linens. | SS=D |
| Failure to submit a Discharge or Death Entry MDS assessment and failure to accurately code specialized services for residents. | SS=D |
| Failure to develop a care plan for a resident with skin tears. | SS=D |
| Failure to update a fall care plan after resident refusal to utilize careplanned fall interventions. | SS=D |
| Failure to complete weekly nursing assessments per physician order for residents with potential impaired skin integrity. | SS=D |
| Failure to maintain safe bed rail dimensions for a resident's bed rail. | SS=D |
| Failure to ensure accurate and detailed description of a resident's fall with major injury in State reportable. | — |
| Failure to ensure adequate supervision during care resulting in a resident falling out of bed and sustaining brain bleeds and facial sutures; failure to have fall interventions and call light available for a resident with a fall and fracture. | SS=G |
Report Facts
Census: 57
Medicare Census: 7
Medicaid Census: 40
Other Payor Census: 10
Bed Rail Opening Dimension: 8.5
Bed Rail Opening Dimension: 15
Skin Tear Size: 1
Skin Tear Size: 0.5
Fall Injuries: 3
Fall Injuries: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelsey Dawn Meal | Laboratory Director or Provider/Supplier Representative | Signed the inspection report |
Inspection Report
Follow-Up
Census: 43
Capacity: 95
Deficiencies: 0
Jan 12, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 12/01/22.
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73, and with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies. The facility applied for a waiver for the corridors being used for return air. The facility is fully sprinkled except for a detached wooden storage shed.
Report Facts
Facility capacity: 95
Census: 43
Inspection Report
Annual Inspection
Census: 44
Capacity: 95
Deficiencies: 18
Dec 1, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including emergency power system testing, exit door locking mechanisms, exit signage, hazardous area door self-closing, fire alarm system maintenance, sprinkler head condition, corridor door functionality, fuel-fired water heater inspections, electrical panel security, GFCI protection in wet locations, HVAC system air return usage, evacuation and relocation plan completeness, combustible decorations, fire door annual inspection, power cord usage, gas cylinder storage, and oxygen transfilling signage.
Severity Breakdown
SS=F: 6
SS=E: 8
SS=C: 4
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements including missing documentation of a three-year 4 hour test. | SS=F |
| Failed to ensure means of egress doors were readily accessible and properly locked with only one latching mechanism; exit door codes were posted incorrectly or missing. | SS=F |
| Failed to install exit signage in the courtyard exit. | SS=E |
| Failed to ensure hazardous area doors had properly working self-closing devices. | SS=E |
| Failed to maintain fire alarm system with accurate time and date information. | SS=C |
| Failed to ensure sprinkler heads in laundry area were free of foreign material and loading. | SS=E |
| Failed to ensure spaces open to corridor had electrically supervised automatic smoke detection for pass-through windows greater than 20 square inches. | SS=E |
| Failed to ensure corridor doors had means suitable for keeping door closed, no impediment to closing, latching, and smoke resistance; some doors were propped open. | SS=E |
| Failed to ensure fuel fired water heaters and boilers had current inspection certificates. | SS=C |
| Failed to secure electrical panels in corridors from unauthorized access. | SS=E |
| Failed to provide ground fault circuit interrupter (GFCI) protection for one wet location receptacle in laundry area. | SS=E |
| Failed to ensure egress corridors were not used as a portion of a return air system serving adjoining rooms. | SS=F |
| Failed to ensure resident rooms did not use multi-plug adaptors as a substitute for fixed wiring. | SS=E |
| Failed to properly secure oxygen cylinders from falling; one cylinder was freestanding without proper restraint. | SS=E |
| Failed to post signs indicating when oxygen transfilling is occurring and prohibiting smoking in the immediate area. | SS=E |
| Failed to provide a complete facility specific written fire safety plan addressing all required components including activation of interconnected fire alarm system upon battery powered isolated smoke alarm activation. | SS=C |
| Failed to ensure combustible decorations on corridor doors did not exceed 30% coverage and were fire retardant or treated. | SS=E |
| Failed to ensure annual inspection and testing of fire door assembly at Oxygen Transfilling room. | SS=E |
Report Facts
Facility capacity: 95
Census: 44
Deficiencies cited: 18
Estimated cost: 72150
Number of sprinkler heads loaded: 4
Number of corridor doors propped open: 3
Number of cylinders improperly secured: 1
Number of rooms with multi-plug adaptors: 1
Inspection Report
Annual Inspection
Census: 44
Capacity: 44
Deficiencies: 4
Nov 3, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from October 31 to November 3, 2022.
Findings
The facility was found deficient in multiple areas including failure to implement pressure ulcer interventions for residents at risk, improper respiratory care related to nebulizer mask contamination and oxygen flow rates, and failure to ensure RN coverage for at least 8 consecutive hours daily. Additionally, the facility failed to ensure a re-hired staff member had a pre-employment physical examination prior to starting work.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement pressure ulcer interventions for 4 of 6 residents reviewed at risk for pressure ulcers. | SS=E |
| Failure to keep nebulizer masks in bags to prevent contamination and failure to follow physician orders for oxygen liters for 2 of 3 residents reviewed for respiratory care. | SS=D |
| Failure to ensure RN coverage for at least 8 consecutive hours daily, 7 days a week. | SS=D |
| Failure to ensure a re-hired staff member had a pre-employment physical examination prior to starting work. | — |
Report Facts
Census: 44
Total Capacity: 44
Residents reviewed for pressure ulcers: 6
Residents with pressure ulcer deficiencies: 4
Residents reviewed for respiratory care: 3
Residents with respiratory care deficiencies: 2
RN coverage missing days: 4
Date of compliance: Nov 21, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Durr | Director of Nursing | Interviewed regarding pressure ulcer and respiratory care deficiencies and RN coverage |
| Staff 12 | Re-hired staff member without pre-employment physical examination prior to rehire |
Report
File
rtbs12_2567.pdf
Report
File
rywp12_2567.pdf
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