Waters Of New Castle, The

Based on observation, interview and record review, the facility failed to ensure residents were free from a significant medication error when Resident B and Resident C received each others evening medications for 2 of 4 residents reviewed for medication error (Resident B and Resident D). Finding include: 1.Review of the record of Resident B, on 2/17/26 at 10:45 a.m., indicated the resident's diagnoses included, but were not limited to, diabetes, major depression disorder, chronic kidney disease (Kidneys are damaged and unable to efficiently filter waste and excess fluid from the blood) and peripheral vascular disease (circulation disorder involving narrowing or blockage of blood vessels).The admission Minimum Data Set (MDS) assessment for Resident B, dated 1/20/26, indicated the resident was cognitively intact for daily decision making. The physician's medication orders for Resident B, on 1/25/26, indicated the resident was prescribed the following medications at bedtime: carvedilol (blood pressure medication) 25 mg, fenofibrate (cholesterol medication) 145 mg, gabapentin (treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure residents' call lights were with in reach for 2 of 2 residents reviewed for accommodation of needs (Resident 14 and Resident 69). Findings include:1.During an observation on 1/13/2026 11:01 a.m., Resident 14 was sitting in her room in a geriatric chair, the resident's touch pad call light was hanging on the wall behind her bed, not within reach of the resident. The roommates call light was activated. During an interview with the Staffing Coordinator on 1/13/26 at 11:15 a.m., the Staffing Coordinator indicated whoever brought Resident 14 back to her room was responsible to provide her with her call light. The Staffing Coordinator provided Resident 14 with her touch pad call light. Review of the clinical record of Resident 14 on 1/16/26 at 11:15 a.m., indicated the resident's diagnoses included, but were not limited to, chronic heart failure, lack of coordination, unsteadiness on feet, chronic obstructive pulmonary disease, major depressive disorder and osteoarthritis. The care plan for Resident 14, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow a physician's order for humidified oxygen for 1 of 2 residents reviewed for respiratory care. (Resident 13) Findings include:The clinical record for Resident 13 was reviewed on 01/14/2026 at 10:31 a.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), mild intermittent asthma, and anxiety.The Annual Minimum Data Set (MDS) assessment, dated 1/2/26, indicated Resident 13 was cognitively intact.During an observation and interview with Resident 13 on 1/13/26 at 11:13 a.m., the resident indicated they were on oxygen at home. Oxygen was on the resident at 1 L/min (liter per minute) with no humidified oxygen hooked up to the oxygen tank.Resident 13 had a physician's order, dated 1/7/26, that indicated O2 (oxygen) at 1 to 2 L/min (liters per minute) via nasal cannula as needed for shortness of breath and to change the humidifier bottle once weekly, on Tuesday, during the day shift and as needed.The January 2026 Medication Administration Record (MAR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a newly admitted resident had his pain medication available as ordered by the physician for 1 of 1 residents reviewed for pain (Resident 66). Finding include:During an interview with Resident 66 on 1/13/2026 at 11:44 a.m., the resident indicated he had been without his tramadol pain medication since he was admitted to the facility on [DATE]. The nurses told him that it had something to do with the prescription not being signed. The resident indicated his pain level had been a 3 out of a 1 to 10 pain scare (one being no pain and 10 being the worst pain). The resident indicated his left hip was sore because he had broke it and had surgery. During an observation and interview with Resident 66 on 1/14/2026 at 1:01 p.m., the resident indicated he had been requesting his tramadol pain medication every day since admission because he needed to help him walk with his walker. The resident indicated not having his tramadol pain medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to monitor valproic acid levels for a resident with a diagnosis of seizures and receiving Divalproex Sodium for 1 of 5 residents reviewed for unnecessary medications. (Resident 5) Findings include: The clinical record for Resident 5 was reviewed on 1/14/2026 at 11:10 a.m. The resident's diagnoses included, but were not limited to, epilepsy (chronic brain disorder causing recurring seizures), muscle weakness, and chronic kidney disease.The Annual Minimum Data Set (MDS) assessment, dated 9/20/25, indicated Resident 5 was moderately cognitively impaired for daily decision making, had seizure disorder, and received anticonvulsants.During a review of Resident 5's current medication orders on 1/15/26 at 10:51 a.m., Resident 5 was ordered Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium), staff were to administer 1 tablet by mouth two times a day for seizure with a start date of 11/10/25.Resident 5's Electronic Health Record (EHR) indicated no valproic acid levels were drawn or monitored since January 2025.A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code two Minimum Data Set (MDS) assessments related to an antipsychotic medication for 1 of 1 residents reviewed for suicidal attempts. (Resident B) Findings include: The clinical record of Resident B was reviewed on 5-1-24 at 9:52 a.m. His diagnoses included, but were not limited to, anxiety, depression, nightmare disorder and suicidal ideation. His most recent MDS assessment, a quarterly assessment dated [DATE], indicated he received antipsychotic medications in Section N0415A, related to medications ordered for the resident. However in Section N0450A, the MDS assessment was coded to reflect he did not receive antipsychotic medications, thus negating the use of a gradual drug reduction information for the use of this type of medication. In the prior MDS, an annual assessment, dated 11-17-23, this information was identified in the same manner. In an interview with the MDS Coordinator on 5-1-24 at 11:34 a.m., she indicated it appeared as if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to provide fresh ice water for 1 of 2 residents reviewed for hydration (Resident 4). Finding include: During an observation and interview on 9/27/23 at 1:52 p.m., Resident 4 indicated she had to ask if she wanted ice water, she hasn't gotten fresh ice water since last night. The facility staff were observed passing out fresh ice water and went by Resident 4's room without providing fresh water. During an observation on 9/27/23 at 2:40 p.m., Resident 4 continues to have a half cup of warm water. The resident indicated her and her roommate had not received fresh water since last night. During an observation on 9/28/23 at 9:45 a.m., Resident 4 continues with the same half cup of warm water with no fresh ice water available. During an observation on 9/28/23 at 11:00 a.m., Resident 4 continues with a cup of warm water with no fresh ice water available. Resident 4 was laying in bed with her eyes closed. During an interview and observation on 9/28/23 at 1:42 p.m., Resident 4 had two cups of warm water. The resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident's privacy curtain was wide enough to provide full visual privacy. This affected 1 of 1 resident reviewed. (Resident 32) Findings include: On 9/27/23, at 11:11 a.m., Resident 32's curtain, between her bed and her roommate's bed, was observed and did not extend from the wall at the head of her bed to the wall past the foot of her bed. The area from the foot of her bed to the wall past the foot of her bed was left exposed for approximately 4 feet. The track on the ceiling, that the curtain was hung from, extended from the wall at the head of her bed to the wall that went past the foot of her bed. There were 10 empty curtain hooks in the curtain track. Resident 32 indicated that anyone could see her in her bed if they walked into her room because the curtain didn't go down far enough. On 9/28/23, at 2:45 p.m., Resident 32 was in bed, with her eyes closed, and the curtain between the beds was not wide enough to extend from wall to wall for privacy. Resident 32's record was reviewed, on 9/28/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record reviewed, the facility failed to accurate code six-month prognosis and hospice services (Resident 12) and medications (Resident 16) for 2 of residents reviewed for Minimum Data Set (MDS) accuracy. Findings include: 1. The clinical record for Resident 12 was reviewed on 9/29/2023 at 11:05 a.m. The medical diagnosis included respiratory failure with hypoxia. A Quarterly MDS assessment, dated got 6/28/2023, indicated that Resident 12 did not have a six-month or less prognosis and did not receive hospice services. A Quarterly MDS assessment, dated for 9/28/2023, indicated that Resident 12 did not have a six-month or less prognosis. A physician order, dated 5/6/2021, indicated Resident 12 received hospice services. A hospice recertification, dated 3/19/2023, indicated Resident 12 has a six month or less prognosis if disease runs its normal course and was recertified for hospice services. 2. The clinical record for Resident 16 was reviewed on 9/29/2023 at 10:55 a.m. The medical diagnosis included chronic obstructive pulmonary disease. A Quarterly MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to develop a plan of care for a resident with recurrent Urinary Tract Infections (UTI) for 1 of 1 resident reviewed for UTI (Resident 4). Finding include: Review of the record of Resident 4 on 9/28/23 at 10:28 a.m., indicated the resident's diagnosis included, but were not limited to, chronic Urinary Tract Infection (UTI). The physician order for Resident 4, dated 7/21/23, indicated the resident was ordered to be seen by the urologist for recurrent UTI's. The physician order for Resident 4, dated 8/16/23, indicated the resident was ordered keflex (antibiotic) 250 milligrams (mg) indefinitely for recurrent UTI's. The urology report for Resident 4, dated 9/18/23, indicated the resident was being seen for recurrent UTI's. During an interview with Resident 4 on 9/28/23 at 1:42 p.m., indicated she had a long history of UTI's. During an interview with the Director Of Nursing (DON) on 9/28/23 at 2:20 p.m., verified Resident 4 did not have a plan of care in place for UTI's. The DON indicated it was the responsibility of the Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to assess and monitor bilateral feet edema (swelling) for 1 of 1 resident reviewed for edema (Resident 4). Finding include: During an observation on 9/27/23 at 2:01 p.m., Resident 4 was sitting in a chair, her bilateral feet were swollen. During an observation and interview with Resident 4 on 9/28/23 at 1:42 p.m., the resident was laying in bed, her bilateral feet were swollen. The resident indicated her feet did swell often. The resident indicated nursing had not assessed her feet edema. Review of the record of Resident 4 on 9/28/23 at 10:28 a.m., indicated the resident's diagnoses included, but were not limited to, age related physical debility, osteoarthritis, pain in right/left knee atrial fibrillation, hypertension, urinary tract infection, gout, anxiety and major depressive disorder. The plan of care for Resident 4, dated 10/18/22, indicated the resident was at risk for dehydration related to diuretic medication use. The intervention included, but were not limited to, observe for increased signs of edema and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.