Willows Of New Castle
WILLOWS OF NEW CASTLE in NEW CASTLE, IN — inspection on March 6, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Finding include:
During an interview with Licensed
longer works at the facility administered Resident B one of Resident E's morning medication.
This occurred months ago and LPN 1 was unsure of the date.
The medication error was reported to the Director Of Nursing (DON) who no longer works at the facility.
During an interview with the Nurse Practitioner (NP) on 3/4/26 at 2:37p.m., the NP indicated on 10/17/25 at 9:31 a.m., LPN 1 reported to her that Resident B had received Resident E morning medication of rivastigmine 3 milligrams (mg).
The medication was used to treat dementia.
The medication was not harmful to Resident B and the NP told LPN 1 to monitor the resident's vital signs and to observe for anxiety and tremors every shift for 24 hours.
During an interview with the Regional Nurse Consultant 3 on 3/5/26 at 10:55 a.m., the Regional Nurse Consultant indicated on 10/17/26, there was no assessment, no progress note and no vital signs documented in the Electronic Health Record (EHR) for Resident B after she received Resident E's morning medication.
The floor nurse was responsibility to ensure this was completed for Resident B.
Review of the clinical record of Resident B on 3/4/26 at 1:25 p.m., indicated the resident's diagnoses included, but were not limited to, diabetes, chronic kidney disease, osteoporosis, hypertension, congestive heart failure, depression, anxiety disorder, intellectual disability (below average cognitive function) and cerebral infarction (stroke caused by a blocked or narrow arteries).
The annual Minimum Data Set (MDS) assessment for Resident B, dated 1/1/26, indicated the resident was moderately impaired for daily decision making.
The Medication error policy provided by the Administrator on 3/6/26 at 10:10 a.m., indicated a medication error means the observed or identified preparation or administration of medications or biologicals which was not in accordance with the prescribers order. If a medication error occurs, the following procedure would be initiated: the nurse assesses and examines the resident's condition, monitor and document the resident's condition, including response to medical treatment or nursing interventions, document actions taken in the medical record.
The citation relates to Intake 2665000. 410 IAC(Indiana Administrative Code) 3.1-37(a)
155089 03/06/2026
Willows of New Castle 1023 N 20th St New Castle, IN 47362
During an observation on 3/04/2026 at 1:54 p.m., Resident 51 had bilateral hand contractures with no splints in place.
During an observation on 3/05/2026 at 11:33 p.m., Resident 51 had bilateral hand contractures, the resident had a splint on his left hand and did not have a splint on his right hand.
The splint was observed to be on the resident's bedside table.
During an observation on 3/05/2026 at 12:46 p.m., Resident 51 was sitting in the dining room, the resident had a splint on his left hand and did not have one on his right hand.
Review of the clinical record of Resident 51 on 3/5/26 at 12:55 p.m., indicated the resident's diagnoses included, but were not limited to, traumatic brain injury (a disruption in normal brain function caused by an external force) and dementia (mental decline).
The plan of care for Resident 51, dated 8/22/24, indicated the resident had an alteration in functional performance as evidenced by: Needed assistance from at least one staff member to complete self-care tasks.
The intervention included, but was not limited to, bilateral palm protectors per order.
The Occupational Therapy assessment for Resident 51, dated 1/21/26, indicated the resident had impaired range of motion of the right and left upper extremities due to contractures.
The quarterly Minimum Data Set (MDS) assessment for Resident 51, dated 2/6/26, indicated the resident was severely impaired for daily decision making.
The resident had impairment in range of motion of both of the upper extremities.
The physician's order for Resident 51, dated March 2026, indicated the resident was to have bilateral palm protector or hand orthoses as tolerated at day time and off at night time and bathing (original 10/20/25).
The Medication Administration Record (MAR) for Resident 51, dated March 2026, lacked documentation by the resident of any refusals to wear bilateral palm protector or hand orthoses.
During an interview with the Regional Nurse Consultant (RNC) on 3/5/26 at 2:25 p.m., the RNC indicated floor nurses were responsible to ensure Resident 51 had his bilateral splints in place.
The assistive device and splint policy provided by the Administrator on 3/6/26 at 10:10 a.m., indicated the purpose of the policy was to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function, dignity and quality of life.
The devices included, but were not limited to, orthotic equipment/splints.
The nurse would be responsible for the resident and monitor for the consistent use of the device. 410 IAC (Indiana Administrative Code) 3.1-42(a)(2)
155089 03/06/2026
Willows of New Castle 1023 N 20th St New Castle, IN 47362
meeting their goals. 3.
The care plan interventions will be related to each resident's individual
dementia-like illnesses. 4.
Care and services will be person-centered and reflect each resident's
independence, choice, and safety. 5.
Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. 6. If needed, the environment will be modified to accommodate individual resident care needs. 7.
The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary. 8.
Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker). 9.
All staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill sets to ensure residents' safety and help resident's attain or maintain the highest practicable physical, mental, and psychosocial well-being.
This citation relates to Intakes 2787990 and 2794869. 410 IAC (Indiana Administrative Code) 3.1-37(a)
155089 03/06/2026
Willows of New Castle 1023 N 20th St New Castle, IN 47362
services of a licensed pharmacist.
interview and record review, the facility failed to ensure a resident's ordered medication was
services. (Resident C) Findings include: The clinical record for Resident C was reviewed on 3/5/26 at 11:11 a.m.
His diagnoses included, but were not limited to, dementia (mental decline) with agitation and anxiety.
The hospital discharge orders, dated 2/17/26, indicated staff were to administrator Resident C's Risperidone one time a day, three 0.5 mg tablets.
The resident's next dose was due on 2/17/26 at 4:00 p.m.
The resident was to receive Trazadone at bedtime, one 50 mg tablet.
The resident's next dose was due on 2/17/26 at bedtime.
The nursing admission note, dated 2/17/26 at 4:10 p.m., by Licensed Practical Nurse (LPN) 7, indicated the resident was confused and combative.
Within the first five minutes of arrival, he was up, refusing to wait for a physical therapy evaluation.
He refused to follow staff direction. He moved over to his roommate's area of the room and started to move items around. He then made contacted with the roommate.
Verbal redirection by staff failed and Resident C became physical, lashing out and striking staff.
The February 2026 medication administration record (MAR) indicated Resident C's three 0.5 mg tablets of Risperidone were not administered at 4:00 p.m. on 2/17/26.
The administration of the Resident C's Risperidone since admission was first administered on 2/18/26 at 4:00 p.m.
The February 2026 MAR indicated Resident C's 50 mg tablet of Trazadone was not administered at bedtime on 2/17/26.
The administration of Resident C's Trazadone since admission was first administered on 2/18/26 at bedtime.
The nursing note, dated 2/17/26 at 10:06 p.m., by LPN 7, indicated Resident C was temporarily moved to another room, because he and his roommate were screaming at each other.
Resident C was found in another resident's room. He was combative with redirection by staff. An interview was conducted with LPN 7 on 3/5/26 at 2:27 p.m.
The LPN indicated he was the nurse on duty when Resident C was admitted to the facility on [DATE].
Resident C's discharge medications were unavailable for administration when he arrived at the facility, including his scheduled Risperidone.
The resident's medications were not available until his second day there. An emergency behavior medication was administered with little to no effect.
The resident was having behaviors and difficult to redirect after arrival.
The Pharmacy Services policy was provided by the Administrator on 3/6/26 at 12:20 p.m. It indicated, The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.
This citation relates to Intakes 2787990 and 2794869. 410 IAC (Indiana Administrative Code) 3.1-25(a)
During the tour, the stove hood was observed.
There was a griddle/stove underneath the left side of the hood.
The hood had a significant amount of built-up, greasy debris on the back panels and sprinklers.
The back panels appeared furry substance completely covering the panels and sprinklers.
There was stringy debris of dark substance hanging from one of the sprinklers above the griddle/stove where food was prepared.
The sticker on the front of the stove hood indicated it was last serviced on 11/26/25, and the next service was to be in May of 2026. An interview was conducted with the DM during the above observation on 3/2/26 at 12:30 p.m.
She indicated they regularly used the griddle/stove underneath the hood, and she noticed the amount of built-up debris on the stove hood, but she was told not to clean it, because it would void the warranty.
After reviewing the next scheduled service visit on the sticker, she indicated perhaps it needed scheduled to be cleaned more often than every six months.
The work order for the stove hood cleaning, dated 11/26/25, was provided by the DM on 3/2/26 at 12:47 p.m. It indicated cleaning of the kitchen exhaust system every 180 days for two years.
The Sanitation policy was provided by the Administrator on 3/6/26 at 2:06 p.m. It indicated, All food service areas shall be kept clean, sanitary, free from litter, rubbish . 410 IAC (Indiana Administrative Code) 3.1-21(i)(3) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155089 03/06/2026
Willows of New Castle 1023 N 20th St New Castle, IN 47362
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.