New Castle Health and Rehabilitation Center

Inspectors wroteBased on document review, interviews, and facility policy review, the facility failed to ensure that one of four residents (Residents (R) 133) reviewed for tube feeding was assessed and monitored for nutritional and fluid needs and to intervene when resident (R133) aspirated tube feeding through the nose and mouth multiple times and gained a significant amount of weight. This failure resulted in harm to R133 when he went into cardiac arrest once while aspirating and was hospitalized three times after aspiration of tube feeding. [...]

Inspectors wroteBased on observations, record review, interviews, and review of facility policy, the facility failed to ensure consistent implementation of interventions to prevent falls for one (Resident (R ) 67) out of 11 residents reviewed for accidents out of total sample of 35 residents. The facility's failure to ensure consistent interventions were implemented to prevent falls for R67 resulted in harm when R67 experienced a fall with major injury (a hip fracture). This failure increased the risk of other residents falling with major injury. and resulted in the potential for this and other residents to experience additional falls with injury.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure food was discarded and/or stored according to professional standards for food service safety in one of one kitchen. This failure had the potential to cause the spread of foodborne illness to all 109 residents that receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. have an adequate water management program. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaires' disease (a serious pneumonia infection) within a healthcare facility. This failure created the potential for the 105 facility residents, who were either over the age of 65 and/or were autoimmune compromised, to be infected by Legionella and 2. ensure one Licensed Practical Nurse (LPN)4 performed hand hygiene between wound treatments for one (Resident (R) 10) . This has the potential for cross-contamination of pathogens from one wound which can then be transferred to another.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure risk vs benefits was explained to the resident or representative prior to the use of psychotropic medications for four (Residents (R )67, R20, R39, and R4) out of five residents reviewed for unnecessary medication out of a total sample of 35 residents. This facility's failure created the potential for residents to receive medications that were not necessary or desired related to their psychiatric/mental health care.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure timely reporting of allegations of potential abuse/neglect for four (Residents (R ) R67, R126, R134, and R39) out of seven residents reviewed for abuse out of a total sample of 35 residents. The facility's failure to ensure timely reporting of the allegation of abuse created the potential for these and other residents to experience ongoing effects related to abuse.

Inspectors wroteBased on interviews, record review, and review of the facility's policy, the facility failed to complete a thorough investigation of an allegation of abuse for three (Residents (R) 134, R126, and R67) of seven residents reviewed for abuse out of 35 sampled residents. The facility's failure to complete a thorough investigation placed residents at risk of being unprotected from Abuse.

Inspectors wroteBased on record review, observations, interviews, and review of facility policy, the facility failed to ensure a splint was applied routinely for one (Resident (R ) R2) out of five residents reviewed for position and mobility out of a total sample of 35 residents. The facility's failure to ensure R2's splint was routinely applied created the potential for this and other residents to experience an unnecessary decline in Range of Motion (ROM).

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure consistent and comprehensive management of nutritional services for one Resident (R ) R67) out of three residents reviewed for nutrition out of a total sample of 35 resident. The facility's failure to ensure consistent nutritional interventions were provided for R67 created the potential for this and other residents to experience significant/unanticipated weight loss or nutritional deficits.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure bed rails in use were necessary for one (Resident (R) 2) of 11 residents reviewed for accidents out of a total sample of 35 residents. The facility's failure to ensure the necessity of R2's bed rails created the potential for this and other residents to experience accidents related to the use of unnecessary bedrails.

Inspectors wroteBased on review of facility policy, record review, observations and interviews, the facility failed to ensure a medication rate of less than five percent when two errors were made out of a total of 25 opportunities, during the administration of (one Resident's (R) 114). The facility's observed medication error rate was eight percent. The facility's failure created the potential for R114 and other residents to experience negative physical and/or psychosocial effects related to the incorrect administration of their medication. A total of 35 residents were reviewed in the sample.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents (Residents (R) R102) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards of 35 sampled residents. The facility failed to offer R102 and/or their representative the opportunity to be vaccinated with one dose of Prevnar 15 (PCV15), PCV20, or PCV21 after the final pneumococcal vaccination. This practice had the potential to increase the risk for this resident to contract pneumonia.

Inspectors wroteR2 was admitted to the facility on [DATE], according to the resident's admission Record, found in the Electronic Medical Record (EMR) under the Profile Tab. The resident's diagnoses included Anoxic Brain Damage and Persistent Vegetative State. Observations of R2 on 12/09/25 at 2:38 PM, on 12/10/25 at 9:04 AM, 10:03 AM, 11:59 AM and 1:18 PM, and 12/11/25 at 10:31 AM, revealed grab bars raised on both sides of the resident's bed. The resident was laying in her bed in a vegetative state and unable to move her body. Observations of R2 laying in her bed in a vegetative state and unable to move her body were conducted on 12/09/25 at 2:38 PM, on 12/10/25 at 9:04 AM, 10:03 AM, 11:59 AM and 1:18 PM, and 12/11/25 at 10:31 AM. Grab bars were raised on both sides of the resident's bed during all of the observations. [...]

Inspectors wrote2. Cross refer to F610, F658 example 2 Review of R5's clinical record revealed: 1/20/23 - R5 was admitted to the facility for long term care. 1/18/25 - R5's care plan for Behavioral Symptoms. Resident is a threat to self and/or others R/T (related to) episodes of aggression and elopement attempts was updated with an intervention for 1:1 observation for safety. 2/11/25 - The quarterly MDS assessment documented that R5 was cognitively impaired with a BIMS score of 5; independent for toileting/showering/dressing/ambulating; active diagnoses included, but were not limited to: dementia, seizure disorder and depression; history of falls; current medications include antipsychotic, antidepressant and anticonvulsant; and the use of a wander/elopement alarm. [...]

Inspectors wroteBased on interview and review of a clinical record and other documentation as indicated, it was determined that for one (R5) out of five residents reviewed for accidents, the facility failed to have evidence of a thorough investigation for a cognitively impaired resident who was identified at the hospital with multiple injuries of unknown origin.

Inspectors wroteBased on record review and interview, it was determined that for one (R5) out of three residents reviewed for discharge, the facility failed to allow R5 to return to the facility and also failed provide a 30 day discharge to his family representative.

Inspectors wroteBased on interview and record review, it was determined that for two (R1 and R5) out of five residents sampled for accidents, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by failing to have a registered nurse (RN) complete and document an RN admission assessment and post-fall assessment.

Inspectors wroteBased on record review and interview, it was determined that for one (R1) out of four residents reviewed for accidents, the facility failed to have his advanced directive and copy of his DPOA (Durable Power of Attorney) readily accessible on his EMR during his 11/6/24 admission.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure foods were labeled, dated, sealed, and stored according to professional standards for food service safety in one of one kitchen. This failure had the potential to cause the spread of foodborne illness to all 115 census residents.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure all pureed foods on the menu were served to the seven residents who received pureed diets out of a total census of 115 residents. This failure placed the residents on pureed diets at risk for hunger, dissatisfaction with meals, unplanned weight loss, and malnutrition.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to assess a resident for self-administration of medication for one of one resident (Resident (R) 7) reviewed for self-administration of medication of 37 sample residents. This had the potential to affect resident medication safety at the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents had access to call lights when needing assistance from staff for one of three residents (Resident (R) 73) reviewed for call lights out of 37 sample residents. This failure had the potential to affect resident safety.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to protect two of four residents right to be free from physical abuse, Resident (R) 218 from physical abuse by R26, and R316 from physical abuse by R42 of 37 sample residents. This failure could lead to the potential of physical abuse towards other residents throughout the facility.

Inspectors wroteBased on interviews, record review, and review of the facility's policy, the facility failed to report allegations of abuse to the appropriate reporting authority for two of four residents (Residents (R) 316 and R216) reviewed for abuse of 37 sample residents. This failure had the potential to affect resident safety at the facility.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a thorough investigation was completed related to an allegation of physical abuse for one of four residents (Resident (R) 216) reviewed for abuse of 37 sample residents. This failure created the potential for R216 to experience further abuse.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the care plan was updated to reflect the use of a palm guard to address contractures for one of two residents (Resident (R) 89) reviewed for contractures of 37 sample residents. This failure placed R89 at risk for inconsistent use of the palm guards which could lead to pain and skin breakdown related to hand contractures.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure proper nephrostomy tube care for one of three residents (Resident (R) 367) reviewed for ostomy care of 37 sample residents. This failure has potential to cause residents to have urine back flow and cause blockage and infection.

Inspectors wroteBased on observation, interviews, record review, and review of the facility's policy, the facility failed to ensure personal protective equipment (PPE) was utilized properly with proper hand hygiene during wound care for one of one resident (Resident (R) 92) reviewed for transmission-based or enhanced barrier precautions of 37 sample residents. This failure had the potential to contribute to the spread of infection among staff and residents.

Inspectors wroteBased on interview and record review, it was determined that for six (R25, R29, R31, R43, R56 and R119) out of six residents reviewed for advance directive, the facility failed to offer the opportunity to formulate an advance directive for each resident.

Inspectors wroteBased on record review and interview, it was determined that for three (R29, R43 and R99) out of six residents reviewed for physician services, the facility failed to ensure each resident was seen for the required physician visits.

Inspectors wroteBased on record review and interview it was determined that for five (E19, E22, E23, E24 and E25) out of five CNAs (certified nurse's aides) reviewed, the facility failed to provide proof of annual performance reviews.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that the start dates were documented when over the counter medications (bottles) were opened in four out of four medication carts reviewed during medication administration. 1/22/24 8:25 AM - During the medication administration observations, this surveyor observed multiple opened bottles of over-the-counter medications in the medication drawers. The bottles lacked the dates when they were opened. During an interview, E56 (LPN) stated, I did not know we had to put start dates on the medications. 1/23/24 11:30 AM - During a phone interview E53 (pharmacist) stated, I reviewed the medications carts this month, and gave the report to the administration to take care of. A review of E53's report revealed documentation of medications without start dates on all four medication carts. 1/29/24 2: [...]

Inspectors wroteBased on record review and interview, it was determined that for eight (R25, R29, R31, R50, R56, R99, R123 and R276) out of thirty (30) residents clinical records reviewed, the facility failed to ensure that each residents' record was complete, accurately documented and readily accessible.

Inspectors wroteBased on observation and record review, it was determined that the facility failed to promote R2's dignity by keeping R2's urinary collection bag in a privacy bag.

Inspectors wroteBased on interview and record review it was determined that for one (R474) out of one resident reviewed for choices, the facility failed to ensure the right to self-determine when R474's preference for showers were not completed.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that R106 was free from side rails that were not required to treat the resident's medical condition. A facility policy titled, Bed rail policy, dated 3/10, and revised 4/24/23 documented, The use of bed rails will be limited to circumstances where they are used to treat a medical condition and enhance the residents' functional abilities. 11/7/22 - R106 was admitted to the facility with diagnoses including muscles weakness, and seizure disorder. 11/7/22 - R106's admission side rail assessment documented, No medical needs, and resident does not benefit from the use of side rails. 4/27/23 - R106's quarterly nursing side rail assessment documented, No medical needs for bed rails, and resident does not benefit from side rails. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined for one (R106) out of three residents review for resident assessment the facility failed to accurately document R106's side rails on the MDS assessments. 11/7/22 - R106 was admitted to the facility with diagnoses including muscles weakness, and seizure disorder. 1/24/23 11:29 AM - R106's medical records documented, .[R106's] sister requested that side rails be placed on the bed .care plan updated, nurse practitioner made aware. 1/24/24 9:00 AM - A review of R106's MDS assessments for the dates of 2/7/23, 2/24/23, 5/23/23, 7/25/23, 10/19/23, and 1/1/24 documented, No bed rails. During an interview E52 (UM) stated, I have been working here for about one and a half year, and he [R106] has had those side rails. During an interview with the E53 (LPN RNAC) stated, I did not know that he [R106] had side rails. [...]

Inspectors wroteBased on interview and record review it was determined that for one (R84) out of three residents reviewed for PASARR, the facility failed to ensure a referral for a new PASARR screening after changes to R84's mental health diagnoses.

Inspectors wroteBased on observation, interview and record review for one (R106) out of three residents reviewed for careplans, it was determined that the facility failed to accurately develop and implement a comprehensive person-centered care plan for R106's use of bed rails.

Inspectors wroteBased on record review, interview and review of facility documentation, it was determined that for one (R524) out of two residents reviewed for discharge, the facility failed ensure that R524's discharge needs regarding his wound care were identified.

Inspectors wroteBased on record review and interview it was determined that for one (R476) out of three residents reviewed for accidents the facility failed to ensure R476 received adequate supervision during a transfer.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R31) out of three residents reviewed for bowel and bladder, the facility failed to ensure that R31 was appropriately assessed on admission to ensure that treatment and services were provided to promote continence of bladder and bowel to the extent possible. 10/31/23 - R31 was admitted to the facility with diagnoses including muscle weakness gait abnormality and diabetes. 10/31/23 - R31's admission bowel and bladder assessment lacked documentation of whether she was continent or incontinent of bowel. R31's bladder assessment documented, no altered bladder elimination. 10/31/23 - R31's [NAME] (electronic record for care givers for resident's care) documented, Assist of one (1) with mobility, provide incontinence care as needed. [...]

Inspectors wroteBased on record review and interview it was determined that for one ( R475) out of four residents reviewed for nutrition the facility failed to implement interventions related to risk for weight loss when the weekly weights were missed and percentage of supplement consumed was not documented.

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that for two (R525 and 274) out of five residents reviewed for pain, the facility failed to ensure that that adequate pain management was provided for R525 and R274 pain assessments were not conducted with a consistent scale for pre and post pain assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess R106's medical condition for the necessary use of two (2) bed rails. Additionally, the facility failed to ensure the bed rail padding was provided on the bed rails as documented in R106's medical records.

Inspectors wroteBased on record review and interview, it was determined for one (R274) out of five sampled residents for pain the facility failed to provide routine pharmaceutical services for acquiring and receiving medication.

Inspectors wroteBased on interview and record review, it was determined that for two (R54, R98) out of five residents (R2, R43, R54, R98, R106) reviewed for unnecessary medications, the facility failed to ensure that R54's PRN for Lorazepam Gel 1 mg for anxiety was limited to 14 days, and R98's PRN order for Alprazolam 1 mg for anxiety was limited to 14 days.