Waters of New Castle, The

In the surveyor’s words

From the most serious findings on record at Waters of New Castle, The, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 14, 2026

  Based on observation, interview, and record review, the facility failed to transfer a resident with a mechanical lift in a safe manner resulting in the resident sustaining a laceration to the forehead requiring 5 stitches and an acute fracture above the knee for 1 of 3 residents reviewed for accidents (Resident D). Finding include:Review of the record of Resident D on 4/13/26 at 12:00 p.m., indicated the resident's diagnoses included, but were not limited to; dated 2/13/26, acquired absence of left leg below the knee amputation; dated 3/27/26, laceration to the forehead requiring 5 stitches; and dated 4/6/26, an acute comminuted angulated fracture involving the distal femoral metaphysis of the left leg acute fracture above the left knee (above the knee fractured bone caused by trauma) and… […]

• Actual harm, isolatedF684Aug 24, 2022

  The facility failed to obtain a [MEDICATION(S)] level (medication therapeutic level), and complete blood count (CBC) ordered for increased white blood cell (WBC) count for a resident experiencing increased confusion, mild but significant leukocytosis (WBC), and increase coughing resulting in hospitalization for pneumonia for 1 of 4 residents reviewed for compliance with laboratory orders. (Resident G) Findings include: The clinical record for Resident G was reviewed on 8/22/2022 at 1:35 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set Assessment, dated 5/26/2022, indicated that Resident G had a mild cognitive impairment and needed assistance with all activities of daily living. […]

• Actual harm, isolatedF686Jan 13, 2022

  Based on observation, interview and record review, the facility failed to identify an alteration in skin integrity that was later identified as an unstageable pressure ulcer, initiate treatments for an identified alteration in skin integrity, sign-off treatments for pressure ulcers, and conduct weekly wound assessments for 3 of 4 residents reviewed for pressure ulcers (Resident B, C and D). Findings include: 1. The clinical record for Resident B was reviewed on 1/12/2022 at 1:24 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment, dated 9/30/2021, indicated Resident B was cognitively impaired and needed extensive assistance of two staff members for bed mobility and extensive assistance of one staff member for hygiene tasks. […]

• Actual harm, isolatedF686Jul 12, 2021

  Based on interview and record review, the facility failed to ensure a treatment was initiated after identification of stage 2 pressure ulcers [partial thickness ulcer] that worsened and resulted in hospitalization related to [CONDITION(S)] [condition that occurs when the body's response to an infection damages its own tissues], failed to assess skin impairments that were documented as present upon admission to the coccyx and buttocks/gluteus, complete treatments for pressure ulcers as ordered by the physician, and follow recommendations from the wound clinic for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: 1a. The clinical record for Resident B was reviewed on 7/9/21 at 11:30 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF692Jan 13, 2022

  Based on interview and record review, the facility failed to ensure weights were obtained for residents identified at risk related to wounds, significant weight loss, and re-admission from the hospital for 4 of 4 residents reviewed for nutritional status (Resident B, C, D, and E). Findings include: 1. The clinical record for Resident C was reviewed on 1/12/22 at 1:15 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly wound evaluation, dated 11/3/21, indicated an unstageable pressure ulcer to Resident C's left heel. The wound to Resident C's left heel was still present as of 1/13/22. […]