Waters Of New Castle, The
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Indiana.
- Location
- 1000 N 16th St, New Castle, Indiana 47362
- CMS Provider Number
- 155304
- Inspections on file
- 30
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Waters Of New Castle, The during CMS and state inspections, most recent first.
A resident with a left BKA, ESRD on dialysis, and high fall risk was care planned for mechanical lift transfers requiring two staff. Despite this, a CNA performed a mechanical lift transfer alone, stating she believed others were busy and wanted to get the resident up for breakfast before dialysis. During the transfer, the resident leaned forward, slid out of the sling, and fell headfirst to the floor, sustaining a forehead laceration requiring stitches and later being found to have an acute comminuted angulated distal femur fracture above the knee. A nurse responding to the incident found the resident on the floor with profuse bleeding from the forehead, and subsequent observations documented facial bruising, a hip bruise, and an above-knee immobilizer on the affected leg.
Two residents received each other’s bedtime medications after an RN set up their medications in cups and mixed them up, despite one resident questioning the unusually high number of pills. One resident with diabetes, chronic kidney disease, and vascular disease received multiple psych, GI, and other medications instead of his ordered carvedilol, fenofibrate, gabapentin, and oxycodone, while the other resident with cerebral palsy, dementia, and psychiatric diagnoses received those medications instead of his ordered regimen. The facility’s medication administration policy, which required verifying orders, checking labels and doses against the MAR, and confirming resident identity, was not effectively followed, resulting in this significant medication error.
The facility failed to accurately code MDS assessments for a resident receiving antipsychotic medication, despite clinical records indicating the use of Zyprexa. Interviews confirmed the coding errors, and the facility lacked a specific policy for the MDS assessment process.
Unsafe Mechanical Lift Transfer Resulting in Head Laceration and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a mechanical lift in accordance with the resident’s care plan and facility/mechanical lift guidelines. The resident had multiple significant medical conditions, including a left below-knee amputation, end-stage renal disease requiring dialysis, and an acute comminuted angulated fracture above the left knee diagnosed later. The resident’s care plan, initiated earlier in the year, specified that transfers required the use of a mechanical lift with two staff members assisting. A fall assessment identified the resident as high risk for falls, and the MDS indicated the resident was cognitively intact for daily decision-making and dependent on staff for transfers. On the date of the incident, progress notes documented that the resident was found lying on the floor on her back after reporting that she slid forward out of the mechanical lift. An emergency department note recorded that the resident was dropped headfirst from a mechanical lift at the facility and complained of head, neck, and back pain. The resident had a 3.0 cm laceration with indentation to the left frontal scalp, which required repair with five stitches. CT scans of the head and spine were negative for acute intracranial abnormality or spine fracture. A nurse who responded to the incident reported hearing a loud noise, finding the resident on her left side with a large gash to the forehead, and observing profuse bleeding that did not stop with applied pressure. Staff interviews and documentation confirmed that the transfer was performed by a single CNA, contrary to the resident’s care plan and facility guidelines requiring two staff for mechanical lift use. The CNA stated she hooked all four straps to the lift and began the transfer alone because she thought everyone was busy and wanted to get the resident up for breakfast before dialysis; she reported that the resident leaned forward and fell out of the sling onto her face. The CNA acknowledged she had been trained that two staff were required when using a mechanical lift. Subsequent documentation showed that the resident later complained of left leg pain during dialysis and was sent to the emergency room, where imaging revealed an acute comminuted angulated fracture involving the distal femoral metaphysis of the left leg. Observations days later noted a scabbed forehead laceration, facial bruising, a large pink bruise on the left hip, and an above-knee immobilizer on the left leg.
Medication Cup Mix-Up Leads to Two Residents Receiving Each Other’s Bedtime Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors when two residents received each other’s evening medications. On the evening in question, a nurse (RN 1) prepared bedtime medications for two residents whose rooms were next to each other and placed the medications into separate cups. RN 1 then mixed up the cups, resulting in each resident receiving the other’s prescribed bedtime medications. One resident, who was cognitively intact for daily decision making, questioned the number of pills because he did not usually take that many medications in the evening but proceeded to take them. One of the residents involved, Resident B, had diagnoses including diabetes, major depressive disorder, chronic kidney disease, and peripheral vascular disease. His bedtime medication orders included carvedilol 25 mg, fenofibrate 145 mg, gabapentin, and oxycodone 10 mg. Instead of these medications, he was administered Tylenol 500 mg two tablets, baclofen 10 mg, clonazepam 0.5 mg, ferrous sulfate 325 mg, florastor 250 mg, guaifenesin 200 mg, remeron 15 mg, pantoprazole, tamsulosin, and geodon 60 mg. The following morning, he reported to the DON, with a family member present, that he had received another resident’s medications and stated he felt very tired and sleepy. The other resident, Resident C, had diagnoses including borderline personality, cerebral palsy, anxiety, psychotic disorder, dementia, and muscle weakness, and was severely impaired for daily decision making. He was allergic to haldol and prozac. His bedtime medication orders included Tylenol 500 mg two tablets, baclofen 10 mg, clonazepam 0.5 mg, ferrous sulfate 325 mg, florastor 250 mg, guaifenesin 200 mg, remeron 15 mg, pantoprazole, tamsulosin, and geodon 60 mg. Instead, he was administered carvedilol 25 mg, fenofibrate 145 mg, gabapentin, and oxycodone 10 mg. The DON, Medical Director, and Nurse Practitioner were notified that the residents had received each other’s medications. The facility’s own medication administration policy required verifying a physician’s order, checking the medication label and dose against the MAR, and confirming the resident’s identity, but these steps were not effectively followed, resulting in the medication error.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately code two Minimum Data Set (MDS) assessments for a resident who was receiving antipsychotic medication. The resident, who had diagnoses including anxiety, depression, nightmare disorder, and suicidal ideation, was documented in the MDS assessment as not receiving antipsychotic medications, despite clinical records indicating otherwise. Specifically, the resident's quarterly MDS assessment and prior annual MDS assessment both incorrectly reflected that the resident did not receive antipsychotic medications, which impacted the documentation of gradual drug reduction information for this type of medication. Interviews with the MDS Coordinator and the Executive Director confirmed the coding errors. The MDS Coordinator acknowledged that the resident had received Zyprexa, an antipsychotic medication, during the look-back periods for both MDS assessments. The Executive Director indicated that the facility did not have a specific policy or procedure related to the MDS assessment process and relied on the current Resident Assessment Instrument (RAI) Manual for guidance. The review of the resident's medication administration records corroborated that the resident had been administered Zyprexa during the relevant periods, highlighting the discrepancy in the MDS coding.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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