Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 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 August 2026) and official state health department websites.