Inspection Reports for
Willows of New Castle

This citation relates to Complaint 2566622. The resident eloped on 7-18-25, was found on facility grounds with a non-emergent skin tear, and was subsequently discharged to a secured memory care unit. The facility investigation included staff interviews, staff education, elopement drills, and environmental audits. The resident was assessed as at risk for elopement and wandering prior to the incident.

The facility failed to prevent a resident from eloping through a window, resulting in a non-emergent skin tear. The facility conducted a thorough investigation, implemented one-on-one supervision, educated staff on elopement policies, secured windows and doors, and updated care plans and risk assessments for wandering and elopement.

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.

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.

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.

The investigation was complaint-driven, focusing on allegations of disrespectful treatment, delayed care response, missed bathing, and lack of routine dental services. The complaints were substantiated with findings of minimal harm and affecting a few residents.

The facility failed to ensure residents were treated with dignity, provide timely assistance with toileting, deliver bathing as requested and care planned, and offer routine dental care when an inside source was unavailable.

Complaint IN00449670 - Federal/state deficiencies related to the allegations are cited at F684 and F690.

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.

This citation relates to Complaint IN00449670 regarding infection control and treatment deficiencies for residents with c-diff and urinary tract infections.

The facility failed to ensure thorough and accurate assessments and documentation for residents diagnosed with c-diff and urinary tract infections. Documentation inconsistencies and lapses in infection control practices were noted, including inadequate monitoring of stooling status and urinary symptoms, and failure to properly update infection surveillance logs.

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.

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.

This Federal tag relates to Complaint IN00425076.

The facility was found deficient in multiple areas including failure to complete self-administration assessments, inadequate hydration provision, failure to honor resident preferences, unclean environments, inaccurate MDS assessments, incomplete care plans, failure to update fall care plans, incomplete weekly nursing assessments, inadequate supervision leading to resident falls with injury, and unsafe bed rail dimensions.

This Federal tag relates to Complaint IN00425076.

The facility failed to provide adequate supervision during care, resulting in a resident falling out of bed and sustaining serious injuries. Additionally, the facility failed to implement fall interventions including the use of two assistive devices and ensuring a call light was available for a resident with a prior fall and fracture.

Complaint IN00425076 was investigated and federal/state deficiencies related to the allegations were cited at F-689 and F-9999.

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.

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.

The facility failed to implement appropriate pressure ulcer interventions for residents at risk, failed to provide safe and appropriate respiratory care including proper nebulizer mask storage and oxygen flow rates, and failed to ensure registered nurse coverage for eight consecutive hours daily on certain weekends.

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.