Newcastle Place

In the surveyor’s words

From the most serious findings on record at Newcastle Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 31, 2025

  Based on observation, staff interview, and record review, the facility did not ensure adequate supervision for 1 resident (R) (R7) of 3 residents reviewed for elopement.R7 was assessed as at risk for elopement and had a WanderGuard on R7's left ankle. R7 lived on the second floor of the facility and had multiple documented attempts of entering the emergency exit stairwell near R7's room. The facility's WanderGuard system did not work with emergency exit stairwell doors. R7 expressed a desire to jump down the stairwell and staff used medical equipment to block the stairwell and divert R7 from the door. On 5/31/25, R7 exited the building via the stairwell and was found outside near an employee parking lot. The facility did not complete an investigation into R7's elopement. […]

• Actual harm, isolatedF689Apr 22, 2026

  Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 6 residents (R) reviewed for accidents (R3, R5, R8, and R7.) R3's and R5's examples rise to the severity/scope level of G. *R3 was admitted to the facility on [DATE]. On 12/24/25, facility staff assessed R3 to be at high risk for falls. Facility staff did not initiate resident specific fall interventions for R3. According to facility staff, R3 was confused and wandering during the overnight shift. On 12/25/25 at 6:45 AM, R3 was found lying on the floor in R3's room. […]

• No harm, potential for more than minimal, widespreadF812May 20, 2026

  Based on observation, staff interview, and record review the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 38 residents residing in the facility. Hand hygiene was not appropriately completed during dishwashing.Food temperatures were not consistently completed.The facility did not have logs for the 3-compartment sink and sanitizing buckets. Bowls in the kitchen were not stored upside down or covered. The stove was not thoroughly cleaned.Findings include:On 5/18/26 at 9:35 AM, Surveyor completed an initial kitchen tour. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2025

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. The practice had the potential to affect all residents residing in the facility. Staff did not wear hair or beard restraints in the kitchen and kitchenettes. Staff did not have ensure the dishwasher rinse cycle reached the required temperature. In addition, staff did not document dishwasher surface temperatures to ensure proper sanitization. Staff did not test the quaternary sanitizing solution per manufacturer's instructions. Findings include: During an initial kitchen tour that began at 9:11 AM on 2/24/25, Director of Culinary Service (DCS)-D indicated the facility follows the Food and Drug Administration (FDA) Food Code. […]

• No harm, potential for more than minimal, widespreadF812Dec 13, 2023

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 41 residents residing in the facility. The kitchen cooler and dry storage area contained multiple open, undated, and/or expired food items. In addition, one food item was stored uncovered and open to air. The facility did not follow safe food cooling protocol. Staff did not follow appropriate hand hygiene procedures when they prepared/served food. Findings include: On [DATE], Sous Chef (SC)-M verified the facility follows the Food and Drug Administration (FDA) Food Code as their standard of practice. 1. […]