Castle Peak Senior Life and Rehabilitation

Inspectors wroteBased on interviews, record review and observations, the facility failed to ensure residents were free from accidents or hazards for one (#1) of four residents reviewed for accidents hazards out of seven sample residents. Specifically, the facility failed to ensure Resident #1 was provided a hot beverage without injury. Resident #1, was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, unspecified cataract, unspecified macular degeneration (loss in central vision of the eyes), disorientation, unspecified, and restlessness and agitation. On 11/12/25 Resident #1 was provided a hot beverage dispensed from the facility's coffee machine and then heated in the microwave for an additional 30 seconds, per the resident's request, by a staff member. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide reasonable accommodations for one (#2) of three residents out of seven sample residents. Specifically, the facility failed to provide timely accommodations for moving Resident #2's personal belongings during a room change.

Inspectors wroteBased on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for one (#2) of three residents out of seven sample residents. Specifically, the facility failed to report an allegation of verbal abuse towards Resident #2 by the director of nursing (DON) to the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for one (#2) of three residents out of seven sample residents. Specifically, the facility failed to maintain documentation to indicate a thorough investigation was completed after an allegation of verbal abuse towards Resident #2 by the director of nursing (DON).

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents was provided the care and services necessary to ensure a safe discharge from the facility to the community out of three sample residents. Specifically, the facility failed to:-Allow Resident #1 to return to the facility after an unplanned discharge to the hospital;-Provide documentation from Resident #1's physician, including the specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility; and,-Reassess Resident #1 for readmission after he was stabilized at the hospital and ready to return to the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints for one (#1) of three residents out of five sample residents. Specifically the facility failed to: -Ensure Resident #1 had physician's orders for the placement of a wanderguard; and, -Obtain consent to move Resident #1 to the secured unit, which prevented the resident from activities that met his interests.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#10 and #35) of five residents out of 23 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #10 was admitted to the facility for long-term care on 4/6/18 with diagnoses of dementia, stroke, and seizure disorder. Upon admission, the resident weighed 117 pounds (lbs). On 7/30/24, Resident #10 weighed 145.6 lbs. On 9/3/24 the resident weighed 126 lbs. Resident #10 sustained a 18.6 lbs (12.8%) weight loss from 7/30/24 to 8/27/24 in one month, which was considered severe weight loss. Due to the facility's failure to accurately assess and implement nutrition interventions timely the resident's weight continued to decline. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (#23) of three residents reviewed for abuse out of 23 sample residents was kept free from abuse. Specifically, the facility failed to: -Prevent Resident #22 from slapping Resident #23; -Thoroughly investigate a resident to resident altercation between Resident #22 and Resident #23; and, -Put interventions in place to prevent future resident to resident altercations between Resident #22 and Resident #23.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#145) of 23 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #145's vital signs were taken after the resident sustained an unwitnessed fall in her room.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#14 and #37) of five residents reviewed were free from unnecessary psychotropic medications out of 23 sample residents. Specifically, the facility failed to ensure as-needed psychotropic medications for Resident #14 and Resident #37 had an identified end date from the prescriber.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one resident (#5) out of five residents reviewed were free from significant medication errors out of 23 sample residents. Specifically, the facility failed to ensure, for Resident #5: -Antibiotics were started as ordered; -The correct antibiotic was given as ordered; -The physician was notified when the antibiotics were not available; and, -Timely identification and notification of a significant medication error.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#26 and #29) of five residents reviewed for accident hazards out of 19 sample residents. Specifically, the facility failed to: -Conduct a thorough investigation was completed after an unwitnessed fall with injury for Resident #26; -Ensure appropriate and effective preventive fall measures and communication, were in place to prevent recurrence of a fall for Resident #26; and, -Investigate Resident #29's skin conditions and implement preventative measures.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for two (#16 and #18) of five residents reviewed for dementia care out of 19 sample residents. Specifically, the facility failed to: -Ensure Resident #16 was provided meal assistance with dignity and opportunity to achieve her highest level independence as possible with appropriate staff support; and, -Ensure Resident #18 was provided opportunities for meal assistance on 3/14/23 to promote meal intake.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for one (#9) of three residents reviewed for abuse out of 20 sample residents. Specifically, the facility failed to ensure Resident #9 was free from physical abuse from a staff member. Resident #9 was dependent on staff for care and cognitively impaired. Resident #9 was struck in the eye when a staff member threw chocolate at her. The action resulted in a hematoma (bruising) to her right eyelid and was given ice and Tylenol for the pain (see the nurse practitioner's note). The resident reported feeling fearful and per certified nurse aide #8 statement the resident was crying after the incident.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by significant weight loss for one (#20) of two residents reviewed for nutrition status services of 20 sample residents. Specifically, the facility failed to ensure Resident #20 had interventions in place to prevent significant weight loss. Resident #20 experienced significant weight loss of 11.34% within a two month time frame, which was considered significant weight loss. The registered dietitian (RD) had a history with the resident as she had been previously admitted in April 2021, where she experienced a 10 lb (pound) weight loss in seven months. [...]

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure a resident with mental and psychosocial adjustment, received appropriate treatment to attain the highest practicable mental and psychosocial well-being for one (#26) of two residents reviewed for mood and behavior out of 20 sample residents. Resident #26 expressed a preference not to have male caregivers providing activites of daily living (ADL) care. A request of the Resident #26's preference not to have male caregivers was documented on 7/31/21. Resident #26 required two assistance for most of her ADLs. Two CNAs for both the day and night were scheduled on the unit where the resident resided. The review of the schedule between August 2021 and 11/30/21 identified at least one male staff member, on at least one shift, was scheduled to work with the resident on almost a daily basis. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with State law for one (#26) of three residents reviewed for abuse out of 20 sample residents. Specifically, the facility failed to report an allegation on 10/19/21 of potential staff-to-resident sexual abuse and/or physical abuse by Resident #1. Cross-reference F610, failure to timely and thorough investigation of an allegation of abuse. Cross-reference F742 failure to ensure the resident received appropriate treatment to attain the highest practicable mental and psychosocial well-being.

Inspectors wroteBased on record review and staff interviews, the facility failed to thoroughly and timely investigate allegations of physical and sexual abuse involving one (#26) of three residents reviewed for abuse out of 20 sample residents. Specifically, the facility fail to: -Thoroughly investigate an allegation of abuse with injury by a provider after a substantial sized bruise was discovered on the arm of Resident #26; and, -Initiate a timely investigation of documented potential sexual abuse of Resident #26 occuring on 11/20/21. Cross-reference F742 failure to ensure the resident received appropriate treatment to attain the highest practicable mental and psychosocial well-being. Cross-reference F609 failure to report an allegation of physical abuse with injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assure that services being provided met professional standards of quality for one (#20) of one resident reviewed for professional standards. Specifically, the facility failed to ensure Resident #20 had physician orders before performing wound care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide the necessary assistance with activities of daily living (ADL) for one (#5) of five residents reviewed for ADLs out of 20 sample residents. Specifically, the facility failed to provide consistent cueing and dining assistance when required for Resident #5, who had a diagnosis of dementia and required additional assistance at times.

Inspectors wroteIII. Resident #31 A. Resident status Resident #31, age [AGE], was admitted on [DATE] and discharged on 12/2/21. According to the December 2021 computerized physician orders (CPO), diagnoses included hypercalcemia (high calcium levels), acute kidney failure, weakness, hypertension (high blood pressure), depression, and gout. The 10/12/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance of two people with transfers and toileting. She required supervision while walking in the room. The resident had a fall that resulted in major injury. B. Resident interview Resident #31 was interviewed on 11/29/21 at 1:48 p.m. She said that she had a fall about three weeks prior when working with the physical therapist (PT). [...]

Inspectors wroteBased on interviews, observations, and record review, the facility failed to provide adequate maintenance for prevention of infection of a peripherally intravenous (PIV) line for one (#83) of one resident reviewed for PIV care services of 20 sample residents. Specifically, the facility failed to implement computerized physician orders (CPO) and failed to follow professional standards for Resident #83's PIV maintenance.