Willows of New Castle

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 29, 2024

  A.) Based on observation, interview and record review the facility failed to adequate supervision during care and ensure two staff were providing care for a dependent resident resulting in the resident falling out of bed and sustaining 3 brain bleeds and 5 facial sutures (Resident B). B.) Based on observation, interview and record review the facility failed to have fall interventions of two assistive devices in place and failed to have a call light available for a resident who had sustained a fall with a fracture (Resident D). This affected 2 of 4 residents reviewed for accidents (Resident B and Resident D). […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure the stove hood was maintained in a clean sanitary manner. This deficiency had the potential to affected 58 of 58 residents who dine in the facility. Findings include:A tour of the kitchen was conducted with the Dietary Manager (DM) on 3/2/26 at 12:30 p.m. 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. […]

• No harm, potential for more than minimal, patternF686Nov 3, 2022

  Based on observation, interview and record review the facility failed to implement pressure ulcer interventions for residents at risk for developing pressure ulcers for 4 of 6 residents reviewed for pressure ulcers (Resident 24, Resident 33, Resident 46 and Resident 26 Findings include: 1.) During an interview and observation on 10/31/22 at 10:55 p.m., Resident 24 was sitting in a recliner with sock on and both heels flat on the footrest of the recliner. The resident indicated her heels did get raw and the staff normally floated her heels with a pillow in bed, but did not while she was sitting in her recliner. The resident indicated she would not mind if the staff floated her heels while in the recliner. […]

• No harm, potential for more than minimal, isolatedF677Jul 22, 2026

  Based on observation, interview, and record review, the facility failed to assist a dependent resident with nail care for 2 of 8 residents reviewed for ADLs (Activities of Daily Living). (Resident D and Resident J) Findings include:1.) The clinical record for Resident D was reviewed on 7/22/26 at 11:50 a.m. The diagnoses included, but were not limited to, aphasia (inability [or impaired ability] to understand or produce speech), dementia (a decline in mental abilities), and contractures (permanent tightening or shortening of muscles, tendons, skin, or other soft tissues that causes joints to become stiff and restricts normal movement). […]

• No harm, potential for more than minimal, isolatedF690Jul 22, 2026

  Based on interview and record review, the facility failed to provide catheter care as ordered by the physician for 1 of 4 residents reviewed for catheter care. (Resident C) Findings include:The clinical record for Resident C was reviewed on 7/21/26 at 1:36 p.m. The diagnoses included, but were not limited to, intellectual disabilities, urinary tract infections, and obstructive and reflux uropathy (conditions where urine flow is blocked or flows backward into the kidneys). An admission Minimum Data Set (MDS) assessment, dated 5/9/26, indicated Resident C was severely cognitively impaired and had no behaviors for rejection of care. A physician's order, dated 5/18/26, indicated urinary catheter care every shift. […]