Castle Pines Health & Rehabilitation

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety for facility's only kitchen reviewed for food storage. The facility did not ensure foods in the refrigerator were stored, labeled and dated when opened or removed from their original packaging on 7/21/2026. The facility did not ensure that expired foods were removed from the refrigerator on 7/21/2026. This failure could place residents who received their meals from the kitchen at risk of food-borne illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 12 residents (Residents #23 and #61) reviewed for pharmacy services. 1. The facility failed to ensure OTC medications were not kept at the bedside for Resident #23 on 7/21/2026 and 7/22/2026. 2. The facility failed to ensure a syringe of normal saline 0.9% (a solution used to maintain hydration) was not on a bedside table for Resident #61 on 7/21/2026. These failures could place residents at risk for adverse effects including contamination, tampering, and reduced therapeutic effects of medication.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #107) reviewed for infection control. The facility failed to keep Resident #107's nephrostomy (a catheter inserted through the lower back directly into the kidney to drain urine) drainage bag off the floor on 7/21/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food prepared in form designed to meet individual needs for 1 of 5 residents (Resident #1) reviewed for dietary services. The facility failed to follow a mechanical soft diet order on 7/6/26 at approximately 5:40 p.m. when facility staff served Resident #1 a chopped corndog causing Resident #1 to choke. Resident #1 expired in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 7/9/26 at 2:45 p.m. The noncompliance was identified as PNC. The past noncompliance began on 7/6/26 and ended on 7/8/26. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk of choking, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision to prevent elopement for 1 of 1 (Resident #1) resident reviewed for supervision. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 3/23/26 when he walked out the front door of the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 3/23/26 and ended on 3/24/26. The facility corrected the non-compliance before surveyor's entrance. This failure could place residents at risk of not being properly supervised resulting in injury or death.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 6 sampled residents (Resident #24 and Resident #44) and one of one dining rooms reviewed for environment. The facility failed to ensure the dining room was without excessive noise levels during meals for Resident #24, Resident #44 and other residents in the dining room. This failure could place residents at risk for diminished quality of life due to the lack of an enjoyable dining experience.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure the dietary manager, dietary aide and cook effectively wore a hair net to cover all hair. 2. The facility failed to ensure foods stored in the refrigerator and freezer were labeled and dated. 3. The facility failed to ensure foods stored in the pantry were sealed or in a sealed container. These failures could place residents at risk of foodborne illness and food contamination. Findings Include: During an observation on 05/18/2025 at 9:45am and on 05/19/2025 at 11:25, the DM, DA-G, DA-H and [NAME] had hair from under hair covering on the front, sides, and backs of their heads. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 13 residents (Resident #41 and Resident #196) and 6 of 9 staff (CNA A, CNA B, CNA O, CNA P, CNA Q, and LVN R) reviewed for infection control. 1. The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions and performed hand hygiene when providing incontinent care to Resident #41 on 5/18/2025. 2. The facility failed to ensure CNA O performed hand hygiene between passing resident trays on 5/18/25. 3. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 5 of 5 residents who were reviewed for immunizations (Resident #24, Resident #25, Resident #44, Resident #49 and Resident #89). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 residents (Resident #23) reviewed for resident rights. The facility failed to ensure the best friend did not speak degradingly to Resident #23 while attempting to assist with personal care on 5/19/25. These failures placed residents at risk of decreased feelings of self-worth and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #348) reviewed for medication storage. The facility did not ensure a medication named Digestive Enzymes was not stored at the bedside for Resident #348 on 05/18/2025. This failure could place all residents at risk of misuse of medication and decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents were free of significant medication errors for 1 (Resident #1) of 3 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when Resident #1 was administered another resident's medications, Glatiramer Acetate (medication to treat multiple sclerosis) by LVN A on 1/6/2025. The noncompliance was identified as PNC. The noncompliance began on 1/6/2025 and ended on 1/8/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #13) reviewed for accidents and hazards. The facility failed to ensure Resident #13 was provided with adequate supervision to prevent her from falling off the mechanical lift of the facility van on 02/28/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/28/24 and ended on 03/05/24. The facility corrected the non-compliance before survey began. This failure could place residents at risk of harm and serious injuries due to lack of supervision and failure to follow protocols.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to store foods in accordance with professional standards. The facility failed to date opened items placed in the refrigerator and correctly date dry storage items in the kitchen. These failures could place residents who ate the food from the kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for 2 out of 2 meals (the lunch meal on 03/25/24 and breakfast 03/26/24) reviewed for food and nutrition services. The facility failed to ensure residents (Resident # 8 and Resident #150) were served margarine listed on the menu during the lunch meal on 03/25/24 and breakfast 03/26/24. This failure could place residents at risk for unwanted weight loss and decrease satisfaction with meals.

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 6 residents (Resident #41) reviewed for comprehensive care plans. The facility failed to care plan Resident #41's refusals to allow staff to perform tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea)) care. The facility failed to care plan Resident #41's desire to perform her own tracheostomy care. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences for 2 of 12 residents (Residents #41 and #81) reviewed for respiratory care. The facility failed to ensure that Resident #41 was safe to perform her own tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea)) care. The facility failed to ensure Resident #81's nebulizer mask was dated and stored properly between use. These failures could place residents requiring respiratory therapy at risk of hypoxia, infections and not receiving prescribed care and services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #23 and #24) and 1 of 5 staff (MA H) reviewed for infection control. MA H failed to perform hand hygiene during medication administration for Residents #23 and #24 on 3/25/2024. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents environment remained free from accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Residents #4, #8, and #9) reviewed for accidents, hazards, and supervision. 1. The facility failed to adequately supervise Resident #4 when being transferred. Resident #4 sustained a fracture of the proximal tibia (broken bone below the knee) when the Hoyer lift tipped over while being transferred with a Hoyer lift device (a mobility device with a U-shaped base and an overhead horizontal bar with hooks on top. A sling suspended by loops or metal clips attached to the overhead bar with hooks. The lift is used to lift and transport people who cannot safely walk or put weight on either leg) by CNA A on 09/07/23. 2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a MDS assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 3 of 7 (Resident #5, Resident #6, and Resident #7) reviewed for MDS information. The facility failed to encode, complete, and submit a discharge MDS for Resident #5 and Resident #6. The facility failed to encode, complete, and submit a death in facility MDS for Resident #7. This deficient practice could place residents at risk of not having records completed and submitted to the CMS system in a timely manner as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #10) reviewed for quality of care in that: Resident #10 did not receive neurological checks after an unwitnessed fall on 9/16/23. This failure could affect residents who sustain falls and place them at risk for head injury or decline in condition.