New Castle Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at New Castle Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF693Dec 13, 2025

  Based on document review, interviews, and facility policy review, the facility failed to ensure that one of four residents (Residents (R) 133) reviewed for tube feeding was assessed and monitored for nutritional and fluid needs and to intervene when resident (R133) aspirated tube feeding through the nose and mouth multiple times and gained a significant amount of weight. This failure resulted in harm to R133 when he went into cardiac arrest once while aspirating and was hospitalized three times after aspiration of tube feeding. […]

• Immediate jeopardy, isolatedF689May 6, 2025

  2. Cross refer to F610, F658 example 2 Review of R5's clinical record revealed: 1/20/23 - R5 was admitted to the facility for long term care. 1/18/25 - R5's care plan for Behavioral Symptoms. Resident is a threat to self and/or others R/T (related to) episodes of aggression and elopement attempts was updated with an intervention for 1:1 observation for safety. 2/11/25 - The quarterly MDS assessment documented that R5 was cognitively impaired with a BIMS score of 5; independent for toileting/showering/dressing/ambulating; active diagnoses included, but were not limited to: dementia, seizure disorder and depression; history of falls; current medications include antipsychotic, antidepressant and anticonvulsant; and the use of a wander/elopement alarm. […]

• Actual harm, isolatedF689Dec 13, 2025

  Based on observations, record review, interviews, and review of facility policy, the facility failed to ensure consistent implementation of interventions to prevent falls for one (Resident (R ) 67) out of 11 residents reviewed for accidents out of total sample of 35 residents. The facility's failure to ensure consistent interventions were implemented to prevent falls for R67 resulted in harm when R67 experienced a fall with major injury (a hip fracture). This failure increased the risk of other residents falling with major injury. and resulted in the potential for this and other residents to experience additional falls with injury. […]

• No harm, potential for more than minimal, widespreadF812Dec 13, 2025

  Based on observations, interviews, and policy review, the facility failed to ensure food was discarded and/or stored according to professional standards for food service safety in one of one kitchen. This failure had the potential to cause the spread of foodborne illness to all 109 residents that receive food from the kitchen.Findings include:During initial observations of the kitchen on 12/09/25 beginning at 9:47 AM, the following was observed:In the dry storage, there were two 19.5-ounce plastic squeeze bottles of chocolate syrup with an expiration date of 5/16/25.In the walk-in refrigerator, there were three 19.5-ounce bottles of chocolate syrup, three 19.5-ounce bottles of vanilla syrup that were opened. […]

• No harm, potential for more than minimal, widespreadF880Dec 13, 2025

  Based on observation, interview, and record review, the facility failed to 1. have an adequate water management program. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaires' disease (a serious pneumonia infection) within a healthcare facility. This failure created the potential for the 105 facility residents, who were either over the age of 65 and/or were autoimmune compromised, to be infected by Legionella and 2. ensure one Licensed Practical Nurse (LPN)4 performed hand hygiene between wound treatments for one (Resident (R) 10) . […]