Newcastle Place

Inspectors wroteBased on observation, staff interview, and record review the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 38 residents residing in the facility. Hand hygiene was not appropriately completed during dishwashing. Food temperatures were not consistently completed. The facility did not have logs for the 3-compartment sink and sanitizing buckets. Bowls in the kitchen were not stored upside down or covered. The stove was not thoroughly cleaned.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food was served at a palatable and appetizing temperature for 2 residents (R) (R3 and R68) of 3 sampled residents. On 5/18/26, R3 and R68 indicated lunch was served at room temperature and their meals were often not hot. An insulated cart and/or thermal plate warmers were not used to deliver meal trays to R3 and R68's unit.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 6 residents (R) reviewed for accidents (R3, R5, R8, and R7.) R3's and R5's examples rise to the severity/scope level of G. *R3 was admitted to the facility on [DATE]. On 12/24/25, facility staff assessed R3 to be at high risk for falls. Facility staff did not initiate resident specific fall interventions for R3. According to facility staff, R3 was confused and wandering during the overnight shift. On 12/25/25 at 6:45 AM, R3 was found lying on the floor in R3's room. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 2 (R5 & R4) of 9 residents. *R5 spilled hot soup on R5's right abdomen, right lower breast and left pinky assessment on 1/23/26. There is no evidence the nurse spoke with the physician on 1/23/26, a treatment was not ordered until 1/24/26 and the area was not assessed until 1/26/26 by the physician. *The facility did not obtain R4's admission weight on 12/8/25 and daily weights on 12/9/25 & 12/10/25 according to R4's physician orders.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 2 (R7 & R1) of 2 residents reviewed for parenteral fluids are administered in accordance with physician orders and comprehensive person-centered care plan.*R7 was admitted to the facility on [DATE] with a PICC (Peripherally Inserted Central Catheter) which is a soft, thin, flexible tube in a vein used to administer IV (Intravenous) medications and fluids. The facility did not obtain physician orders or create a care plan for R7's PICC line until 4/14/26.*Physician orders for R1's PICC line were not followed on 1/29/26, 2/5/26, 2/7/26, 2/11/26, and 2/16/26.

Inspectors wroteBased on interview and record review the facility did not provide pharmaceutical services ensuring medications were available to be administered as ordered by their physician for 1 (R4) of 3 residents.*R4 has an order to receive Potassium Chloride Crys ER (Extended Release) Oral Tablet Extended Release 10 MEQ for Hypokalemia effective 12/9/25. R4 did not receive this medication on 12/27, 12/28, and 12/29/25. Findings Include:The facility policy titled, Providing Pharmacy Products and Services, dated 6/1/24, documents: . Applicability: This policy 1.0 sets forth procedures relating to the provision of Pharmacy Products and Services in accordance with the Pharmacy Services Agreement. Procedure1. Pharmacy will provide facility with the facility-specific pharmacy information placard which details how facility staff can contact pharmacy twenty-four hours a day, seven days a week.2. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility did not assess a resident's ability to self-administer medication before leaving medication at the bedside for 1 resident (R) (R1) of 5 sampled residents reviewed for self-administration of medication.

Inspectors wroteBased on interview, record review, and facility policy review, the facility did not ensure 1 resident (R) (R1) of 5 residents reviewed for medication administration was free from a significant medication error. On 12/29/25, R1 received duplicate doses of prescribed blood pressure medication. This error resulted in R1 experiencing hypotension (low blood pressure) and requiring evaluation in the Emergency Department (ED).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure adequate supervision for 1 resident (R) (R7) of 3 residents reviewed for elopement. R7 was assessed as at risk for elopement and had a WanderGuard on R7's left ankle. R7 lived on the second floor of the facility and had multiple documented attempts of entering the emergency exit stairwell near R7's room. The facility's WanderGuard system did not work with emergency exit stairwell doors. R7 expressed a desire to jump down the stairwell and staff used medical equipment to block the stairwell and divert R7 from the door. On 5/31/25, R7 exited the building via the stairwell and was found outside near an employee parking lot. The facility did not complete an investigation into R7's elopement. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R)5 (R1 and R15) of 2 sampled residents. R1 reported that R1 was missing $40 and a silver dollar coin. The facility did not report the allegation of misappropriation to local law enforcement. R15 reported that $280 was taken from R15's room. The facility did not report the allegation of misappropriation to the State Agency (SA) or local law enforcement.

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of misappropriation were thoroughly investigated for 2 residents (R) (R1 and R15) of 2 sampled residents. R1 reported that R1 was missing $40 and a silver dollar coin. The facility did not thoroughly investigate the allegation of misappropriation. R15 reported that $280 was missing from R15's room. The facility did not thoroughly investigate the allegation of misappropriation.

Inspectors wroteBased on staff and resident interview, record review, and review of the facility's policy, the facility did not ensure the medical record was complete and accurate for 1 resident (R) (R9) of 9 sampled residents. R9 had medications brought from home that R9 administered independently. The medications were not identified in R9's medical record. This had the potential for staff not to be aware of what medications were being independently administered by R9 which could potentially create a medication error.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. The practice had the potential to affect all residents residing in the facility. Staff did not wear hair or beard restraints in the kitchen and kitchenettes. Staff did not have ensure the dishwasher rinse cycle reached the required temperature. In addition, staff did not document dishwasher surface temperatures to ensure proper sanitization. Staff did not test the quaternary sanitizing solution per manufacturer's instructions.

Inspectors wroteBased on staff interview and record review, the facility did not implement their abuse policy and procedure for 4 of 4 employees reviewed for caregiver background checks. The facility did not complete reference checks for Certified Nursing Assistants (CNA)-J, CNA-K, CNA-L, and CNA-M.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were offered or administered for 4 residents (R) (R12, R30, R148, and R346) of 5 sampled residents. The facility did not offer R12, R30, R148, or R346 the PCV20 vaccine.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R248) of 1 sampled resident received care and treatment based on the resident's needs and medical orders. R248 was not provided wound care for a right below-the-knee amputation (BKA) as ordered. In addition, staff did not monitor R248's vital signs in accordance with the facility's policy

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a fall intervention was implemented for 1 resident (R) (R17) of 2 sampled residents. R17 had a history of falls and a care plan intervention that stated R17's walker should be within reach. The intervention was not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, facility did not ensure proper care and treatment for 2 residents (R) (R250 and R148) of 4 sampled residents who received medication through a peripherally inserted central catheter (PICC) line. R250 and R148's PICC line dressings and injection caps were not changed as ordered.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R12) of 3 sampled residents. R12 had a wound and was on enhanced barrier precautions (EBP). On 2/24/25 and 2/26/25, staff provided care for R12 without wearing the proper personal protective equipment (PPE).

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R1) of 3 sampled residents. On 11/4/24, staff witnessed Licensed Practical Nurse (LPN)-C verbally abuse R1. The facility did not report the verbal abuse to local law enforcement.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 3 sampled residents. On 11/4/24, staff witnessed Licensed Practical Nurse (LPN)-C verbally abuse R1. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmaceutical services to ensure prescribed medication was available and administered correctly for 1 resident (R) (R1) of 8 sampled residents. R1 had an order for heparin sodium injection solution 5000 unit/milliliter (ml) inject 1 ml subcutaneously every 8 hours for blood thinner for 14 days. R1 was not administered heparin as ordered.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 1 resident (R) (R8) of 1 resident observed during the provision of incontinence care. During an observation of perineal care for R8 on 10/28/24, Certified Nursing Assistant (CNA)-K did not appropriately remove gloves and cleanse hands.

Inspectors wroteBased on staff interview and record review, the facility did not implement their abuse policy for 3 of 8 employees reviewed for background checks. Registered Nurse (RN)-K did not have a background check completed within the last 4 years. The facility was unable to provide background check information for Dietary Manager (DM)-L and Certified Nursing Assistant (CNA)-M who were contracted employees.

Inspectors wroteBased on staff interview and record review, the facility did not ensure appropriate care and treatment was provided for 1 resident (R) (R2) of 7 sampled residents. R2 experienced a low irregular heart rate on 5/1/24 and low blood pressure on the morning of 5/3/24. Staff did not notify a physician of R2's change in condition in a timely manner. In addition, staff did not obtain R2's daily weights as ordered.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff used a gait belt during transfers for 4 residents (R) (R4, R5, R6, and R7) of 5 sampled residents. R6's baseline care plan indicated R6 required assistance with transfers. The facility's practice was to use a gait belt for transfers. On 5/29/24, Certified Nursing Assistant (CNA)-G transferred R6 from recliner to wheelchair without a gait belt. In addition, R4, R5, and R7 stated staff did not consistently use a gait belt during transfers.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the accurate administration of medication for 3 residents (R) (R1, R3, and R5) of 5 sampled residents. R1 had an order for oxycodone (an opioid pain medication) as needed (PRN). R1's narcotic count sheet and medication administration record (MAR) did not match. As a result, R1 did not have follow-up documentation for the effectiveness of the medication. In addition, the facility ran out of R1's oxycodone and staff accepted oxycodone brought from R1's home. R3 did not receive 4 doses of prescribed medication because the medications were not available upon admission. R5 did not receive 2 doses of prescribed medication because the medications were not available upon admission.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a medication was administered for its intended use for 1 resident (R) (R1) of 5 sampled residents. R1 was prescribed Benadryl (an analgesic medication) as needed (PRN) for itching. R1 requested and was administered Benadryl for reasons other than itching.

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of abuse were reported timely to the State Agency (SA) or local law enforcement for 5 residents (R) (R5, R6, R7, R3, and R4) of 8 sampled residents. On 2/27/24, R5 and R6 reported allegations of abuse. The facility did not report the allegations of abuse to the SA in a timely manner. On 3/6/24 between 6:30 AM and 6:45 AM, R7 reported an allegation of abuse with injury. The initial report was not submitted to the SA until 3/7/24 at 1:48 PM. On 3/28/24, the facility discovered R3 had a dislocation of the right humerus head. The facility did not report the injury of unknown origin to the SA in a timely manner. On 2/25/24, R4 reported an allegation of abuse. The facility did not report the allegation of abuse to the SA in a timely manner and did not notify local law enforcement.

Inspectors wrote4. On 4/23/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, neurocognitive disorder with Lewy bodies, and aphasia (a language disorder that affects a person's ability to communicate). On 3/28/24, the facility discovered R3 had a right humerus head dislocation which was an injury of unknown origin. The facility interviewed staff and residents, assessed R3, and sent R3 to the Emergency Department (ED). The facility also notified local law enforcement, R3's family, and R3's physician. The facility did not summarize the investigation or identify the cause of injury for R3. On 4/23/24 at 1:31 PM, Surveyor interviewed DON-B who indicated DON-B was not sure of the cause of injury and thought the injury was due to movement when getting dressed. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R7) of 11 sampled residents was free from abuse. The facility did not ensure interventions were implemented after staff members voiced concerns regarding Certified Nursing Assistant (CNA)-E's interactions with residents on 2/27/24. On 3/13/24, the facility submitted a facility- reported incident (FRI) regarding an allegation of abuse that identified CNA-E as the accused staff member.

Inspectors wroteBased on interviews and record review, the facility failed to ensure 1 Resident (R) (R2) of 3 sampled residents reviewed for discharge requirements was allowed to return to the facility. On 12/13/23, R2 was evaluated in the emergency room and deemed appropriate to return to the facility. The facility did not allow R2 to return.

Inspectors wroteBased on interviews and record review, the facility failed to ensure 1 Resident (R) (R2) of 3 sampled residents reviewed for behavioral health services received a psychiatric evaluation as ordered by the physician.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 41 residents residing in the facility. The kitchen cooler and dry storage area contained multiple open, undated, and/or expired food items. In addition, one food item was stored uncovered and open to air. The facility did not follow safe food cooling protocol. Staff did not follow appropriate hand hygiene procedures when they prepared/served food.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection. Staff did not perform appropriate hand hygiene during the provision of care for 1 (R19) of 2 sampled residents. In addition, staff did not offer hand hygiene prior to meal service for 9 Residents (R) (R7, R14, R21, R25, R26, R28, R192, R194, and R195) of 9 residents. Staff did not appropriately wash or sanitize hands during the provision of perineal care for R19. Staff did not offer or provide hand hygiene to R7, R14, R21, R25, R26, R28, R192, R194 and R195 prior to the lunch meal on 12/11/23 and/or 12/12/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a legal representative for 1 Resident (R) (R6) of 5 residents was informed of the risks and benefits of prescribed psychotropic medication and signed consent forms for the medication. R6 was prescribed lorazepam for anxiety and trazadone for depression. (Lorazepam and trazadone are psychotropic medications with a black box warning which is the Food and Drug Administration's (FDA's) most stringent warning that alerts the public and health care providers to serious side effects, such as injury or death). R6's medical record did not contain medication consent forms signed by R6's Power of Attorney for Healthcare (POAHC).

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Culinary Director (CD)-E) of 8 employees reviewed for background checks. CD-E was a contracted staff member. The facility was unable to provide a Background Information Disclosure (BID) form, Wisconsin Department of Justice (DOJ) letter, or Integrated Background Information System (IBIS) letter for CD-E.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R) (R19 and R26) of 2 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R26 was transferred to the hospital on [DATE] due to a change in condition. R26 was not provided with a written transfer notice. R19 was transferred to the hospital on [DATE] following a fall. R19 was not provided with a written transfer notice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R) (R19 and R26) of 2 residents reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R26 was transferred to the hospital on [DATE] due to a change in conation. R26 was not provided with a written Notice of Transfer with Bedhold/Discharge form. R19 was transferred to the hospital on [DATE] after a fall. R19 was not provided with a written Notice of Transfer with Bedhold/Discharge form.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure adequate assistive devices and fall interventions were in place for 1 Resident (R) (R19) of 2 residents reviewed for falls. R19 had a fall on 12/3/23. Fall interventions added to R19's care plan following the fall were not implemented timely.

Inspectors wroteBased on staff interview and record review, the facility did not ensure pharmacy recommendations were acted on by a physician for 1 Resident (R) (R6) of 5 residents reviewed for unnecessary medications. Irregularities identified on R6's monthly pharmacist review were not responded to appropriately or timely by the physician.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for adverse consequences of high-risk medications was completed for 2 Residents (R) (R7 and R6) of 5 residents reviewed for unnecessary medications. R7 was prescribed tramadol (an opioid medication used to help relieve moderate to severe pain). R7's care plan did not contain monitoring for adverse consequences of tramadol. R6 was prescribed tramadol and morphine (an opioid medication used to help relieve moderate to severe pain). R6's care plan did not contain monitoring for adverse consequences of tramadol and morphine.

Inspectors wroteBased on observation and staff interview, the facility did not ensure pureed meals were prepared by methods that conserve nutritive value, flavor, and appearance for 1 Resident (R) (R2) of 1 resident. Kitchen staff did not follow pureed food recipes.