New Castle, IN

Willows Of New Castle

3-star overall rating with 3-star inspections with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

1023 N 20th St, New Castle, IN

(765) 529-9694

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

95

Certified beds

Average residents

54

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1969-03-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.42

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

1.40

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.44

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

4.26

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.82

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.42

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.34

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.37

CMS adjusted RN staffing hours

Adjusted total hours

3.76

CMS adjusted total nurse staffing hours

Case-mix index

1.55

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

60%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,272

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

30.21

Composite VBP score used to determine payment impact.

Payment multiplier

0.9858

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.19

Baseline 20.04% · Performance 19.95% · Measure score 3.19 · Achievement 3.19 · Improvement 0

Healthcare-associated infections

5.09

Baseline 6.10% · Performance 6.31% · Measure score 5.09 · Achievement 5.09 · Improvement 0

Total nurse turnover

1.08

Baseline 47.06% · Performance 59.26% · Measure score 1.08 · Achievement 1.08 · Improvement 0

Adjusted total nurse staffing

2.72

Baseline 2.80 hours · Performance 3.76 hours · Measure score 2.72 · Achievement 2.41 · Improvement 2.72

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.19%
10.72%
1.5 pts better
No Different than the National Rate · Eligible stays 77 · Observed rate 3.9% · Lower 95% interval 6.17%
Discharge to community 60.88%
50.57%
10.3 pts better
No Different than the National Rate · Eligible stays 56 · Observed rate 64.29% · Lower 95% interval 49.25%
Medicare spending per beneficiary 1.09
1.02
0.1 pts worse
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 56 · Denominator 56
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 56
Discharge self-care score 41.86%
53.69%
11.8 pts worse
Numerator 18 · Denominator 43
Discharge mobility score 46.51%
50.94%
4.4 pts worse
Numerator 20 · Denominator 43
Pressure ulcers or injuries, new or worsened 3.57%
2.29%
1.3 pts worse
Numerator 2 · Denominator 56 · Adjusted rate 3.57%
Healthcare-associated infections requiring hospitalization 6.31%
7.12%
0.8 pts better
No Different than the National Rate · Eligible stays 46 · Observed rate 2.17% · Lower 95% interval 3.2%
Staff COVID-19 vaccination coverage 1.79%
8.2%
6.4 pts worse
Numerator 2 · Denominator 112
Staff flu vaccination coverage 82.86%
42%
40.9 pts better
Numerator 87 · Denominator 105
Discharge function score 51.16%
56.45%
5.3 pts worse
Numerator 22 · Denominator 43
Transfer of health information to provider 92.31%
95.95%
3.6 pts worse
Numerator 24 · Denominator 26
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 6.67%
25.2%
18.5 pts worse
Numerator 2 · Denominator 30

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.5
1.6
0.9 pts worse
1.9
0.6 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.7
1.5
1.2 pts worse
1.8
0.9 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.7 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 94.3%
93.6%
0.7 pts better
93.4%
0.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 97.8% · Q3 87.8% · Q4 100.0% · 4Q avg 94.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97.9%
95.4%
2.5 pts better
95.5%
2.4 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9%
Percentage of long-stay residents experiencing one or more falls with major injury 0.6%
3.8%
3.2 pts better
3.3%
2.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 16.4%
24.6%
8.2 pts better
11.4%
5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 25.6% · Q3 21.6% · Q4 10.3% · 4Q avg 16.4%
Percentage of long-stay residents who lose too much weight 5.4%
5.6%
0.2 pts better
5.4%
About the same
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 11.4% · Q3 0.0% · Q4 7.9% · 4Q avg 5.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 30.1%
23.5%
6.6 pts worse
19.6%
10.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 31.6% · Q3 24.3% · Q4 33.3% · 4Q avg 30.1%
Percentage of long-stay residents who received an antipsychotic medication 25.0%
14.8%
10.2 pts worse
16.7%
8.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 28.6% · Q3 30.0% · Q4 21.2% · 4Q avg 25.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.0%
About the same
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 40.4%
13.3%
27.1 pts worse
16.3%
24.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 38.3% · Q2 46.0% · Q3 43.0% · 4Q avg 40.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 36.6%
11.7%
24.9 pts worse
14.9%
21.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 47.2% · Q3 35.3% · Q4 41.7% · 4Q avg 36.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.4%
0.4 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 3.0%
1.2%
1.8 pts worse
1.7%
1.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 7.0% · Q3 2.6% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 25.7%
24.2%
1.5 pts worse
19.8%
5.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 32.6% · Q3 22.8% · Q4 25.7% · 4Q avg 25.7%
Percentage of long-stay residents with pressure ulcers 2.5%
4.1%
1.6 pts better
5.1%
2.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.6% · Q3 2.3% · Q4 2.3% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 83.4%
81.6%
1.8 pts better
81.7%
1.7 pts better
Short Stay · 2024Q4-2025Q3 · Q1 88.7% · Q2 93.4% · Q3 87.5% · Q4 68.4% · 4Q avg 83.4%
Percentage of short-stay residents who had an outpatient emergency department visit 16.0%
10.5%
5.5 pts worse
12.0%
4 pts worse
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 14.0% · Expected 9.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.0%
1.3%
0.3 pts better
1.6%
0.6 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.2% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 89.3%
79.0%
10.3 pts better
79.7%
9.6 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 20.6%
22.4%
1.8 pts better
23.9%
3.3 pts better
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 16.0% · Expected 18.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-14 · Fire 2025-03-14

4 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-01-29 · Fire 2024-01-29

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-11-03 · Fire 2022-11-03

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

18 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-14

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-05-08

F · Potential for more than minimal harm 2025-03-14

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-05-08

E · Potential for more than minimal harm 2025-03-14

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-05-08

E · Potential for more than minimal harm 2025-03-14

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2025-05-08

E · Potential for more than minimal harm 2025-03-14

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-05-08

E · Potential for more than minimal harm 2025-03-14

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-05-08

E · Potential for more than minimal harm 2025-03-14

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-05-08

E · Potential for more than minimal harm 2025-03-14

K791 · Miscellaneous Deficiencies

Fire Safety

Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-03-14

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-03-14

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-05-08

F · Potential for more than minimal harm 2024-01-29

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-03-20

E · Potential for more than minimal harm 2024-01-29

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-03-20

E · Potential for more than minimal harm 2024-01-29

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-03-20

E · Potential for more than minimal harm 2024-01-29

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-03-21

E · Potential for more than minimal harm 2024-01-29

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-03-20

E · Potential for more than minimal harm 2024-01-29

K361 · Smoke Deficiencies

Fire Safety

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Corrected 2024-03-20

E · Potential for more than minimal harm 2024-01-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-03-21

F · Potential for more than minimal harm 2022-11-03

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-01-02

F · Potential for more than minimal harm 2022-11-03

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-01-02

F · Potential for more than minimal harm 2022-11-03

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-01-02

F · Potential for more than minimal harm 2022-11-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K361 · Smoke Deficiencies

Fire Safety

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-01-02

E · Potential for more than minimal harm 2022-11-03

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2023-01-02

C · Minimal harm 2022-11-03

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-01-02

C · Minimal harm 2022-11-03

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2023-01-02

C · Minimal harm 2022-11-03

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2023-01-02

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-28

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Not marked corrected

D · Potential for more than minimal harm 2025-03-14

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-14

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-14

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-01-09

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-01-09

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-02-07

G · Actual harm 2024-01-29

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-29

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2024-02-09

E · Potential for more than minimal harm 2022-11-03

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2022-11-21

D · Potential for more than minimal harm 2022-11-03

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-11-21

D · Potential for more than minimal harm 2022-11-03

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2022-11-21

Penalties and ownership

What sits behind the stars

Ownership

Henry County Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 31 facilities 2012-01-01
Dynes, Sheldon

Corporate Director · Individual

0% 7 facilities 2012-01-01
Frankel, Israel

Operational/Managerial Control · Individual

0% 3 facilities 2025-01-08
New Castle In Opco, LLC

Operational/Managerial Control · Organization

0% 1 facilities 2023-07-01
Pidgeon, John

Corporate Director · Individual

0% 7 facilities 2012-01-01
Ring, Brian

Corporate Officer · Individual

0% 30 facilities 2022-08-01
Shore, Marion

Corporate Director · Individual

0% 7 facilities 2012-01-01
Ware, Deborah

Corporate Director · Individual

0% 5 facilities 2021-08-27

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