Waters of Castleton Skilled Nursing Facility, the

Inspectors wroteBased on observation and record review, the facility failed to ensure a resident's right to privacy and dignity during 1 of 1 care observations in which 1 of 3 residents reviewed for care and services did not have the door or privacy curtain closed in a manner to provide privacy and dignity during the process of transferring the resident from the wheelchair into their bed. (Resident C)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the use of a gait belt (device used to enhance safety during movement while assisting another person) during the transfer of 1 of 3 residents reviewed for care and services during 1 of 1 care observations. (Resident C)

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a urinary catheter bag or its tubing from coming in contact with the floor during 1 of 1 care observations for 1 of 3 residents reviewed for care and services. (Resident C)

Inspectors wroteBased on interview and record review the facility failed to have complete and accurate documentation for a resident's follow- up physician appointments for 1 of 3 residents reviewed for physician appointments. (Resident C).

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff to provide administer medications for 15 of 28 residents reviewed who received medication from the second-floor west hall medication cart. (Resident E, Resident F, Resident G, Resident H, Resident K, Resident M, Resident N, Resident P, Resident R, Resident S, Resident V, Resident W, Resident X, Resident Y, Resident Z)

Inspectors wroteBased on interview and record review, the facility failed to implement procedures that assured the accurate accounting of controlled substance medications for 1 of 3 medication carts reviewed for controlled medication records. (West Hall second floor medication cart)

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to be free from physical abuse by another resident for 2 of 3 residents reviewed for abuse. A resident punched another resident repeatedly. (Resident B, Resident C)

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from misappropriation of property for 1 of 3 residents reviewed for misappropriation of property. A resident's controlled narcotic pain medication was signed out while the resident was in the hospital. (Resident D)

Inspectors wroteBased on observation, interview and record review, the facility failed to timely have the interdisciplinary team (IDT) determine and document that self-administration of medications and treatments were clinically appropriate for 2 of 16 residents reviewed. (Resident B and Resident N)

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 5 residents reviewed for abuse (Resident E).

Inspectors wroteBased on interview and record review the facility failed to document thorough investigations for allegations of abuse for 1 of 5 residents investigated for abuse (Resident F).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a urinary catheter was available for resident use for 1 of 1 resident reviewed for urinary catheters. (Resident G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure new behaviors were documented in the clinical record and to ensure staff were monitoring and tracking behaviors for 1 of 5 residents reviewed for abuse and 1 of 5 residents reviewed for call light response (Resident B and Resident D).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure outdated items were discarded from the refrigerator timely, items were not open to air in the refrigerator, and the kitchen and kitchen equipment were clean with the potential to affect 50 of 51 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to timely discontinue an anti-psychotic medication as recommended by pharmacy and medial provider for 1 of 6 residents reviewed for unnecessary medications. (Resident 7)

Inspectors wroteBased on interview and record review, the facility failed to ensure a transfer form was sent with a resident who was transferred to an acute care hospital for 1 of 2 residents reviewed for hospitalization (Resident 2)

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan accurately reflected resident wishes regarding discharge and to ensure care plan meetings were held timely for 2 of 3 residents reviewed for discharge care plans, 1 of 1 resident reviewed for notification of change, and 1 of 3 residents reviewed for care plans (Resident 4, Resident 37, Resident 36, and Resident 20)1. The clinical record for Resident 4 was reviewed 12/12/2025 at 1:30 p.m. The medical diagnoses included, but were not limited to, diabetes and polyneuropathy. A Quarterly Minimum Data Set Assessment, dated 9/4/2025, indicated Resident 4 was cognitively intact, had no active discharge planning, and did not want to speak to someone about returning to the community. A discharge care plan, dated 8/31/2023 and revised on 11/8/2025, indicated Resident 4 wanted to discharge home. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the optometry plan of care was implemented for a resident with glaucoma for 1 of 1 resident reviewed for vision services ( Resident 17).

Inspectors wroteBased on interview, observation, and record review, the facility failed to address a resident's (Resident 26) pain by ensuring availability of pain medications and implementing other pain relief interventions for 1 of 1 resident reviewed for pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the availability of a resident's seizure medication for 1 of 6 unnecessary medications reviewed. (Resident 58)

Inspectors wroteBased on interview and record review, the facility failed to timely address a pharmacy recommendation to discontinue a resident's medications for 1 of 6 residents reviewed for unnecessary medications. (Resident 5)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received mechanically altered diets, as ordered by the physician, for 3 residents randomly observed at meal service (Resident 25, Resident 31, and Resident 36).

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were accurately documented for the administration of a resident's seizure medication and for the administration of a resident's eye drops for 1 of 6 unnecessary medications reviewed, 1 of 1 resident reviewed for vision services, and 1 or 3 reviewed for potential communication concerns. (Resident 58, Resident 17, and Resident 26)

Inspectors wroteBased on interview, observation, and record review, the facility should ensure the indwelling urinary catheter bag remains free of contact with the floor, that hand hygiene was performed prior to donning gloves, and that the hub of an insulin pen was disinfected prior to attaching the needle, for 1 or 1 residents reviewed for urinary catheters and 1 of 5 residents randomly observed during medication pass . (Resident 8 and Resident 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a resident's antipsychotic medication, as ordered; inform the physician/provider of the medication not having been administered; and implement and revise a resident's behavior care plan regarding refusal of care and medication for 1 of 3 residents reviewed for behavioral Health Services. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a fall intervention was implemented timely after a fall event occurred and fall interventions were in place for 1 of 3 residents reviewed for accidents. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic medication was administered per the physician orders, narcotic medication was readily available for use, and intravenous (IV) antibiotics were obtained to be administered as ordered by the physician for 2 of 3 residents reviewed for medication use. (Resident C and Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure a gradual dose reduction (GDR) was conducted instead of abruptly discontinuing an antidepressant medication and antianxiety medication for 1 of 3 residents reviewed for unnecessary medications. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to honor a resident's right for dignity to 2 of 5 residents reviewed for timely response to call lights and 1 of 1 resident reviewed for incontinence care by offering an incontinence brief. (Resident C and Resident F)

Inspectors wroteA. Based on interview and record review, the facility failed to ensure the attending physician and family were notified in a timely manner of a significant weight loss in less than 30 days for 1 of 2 residents reviewed for gastric feedings. (Resident G) B. Based on interview and record review, the facility failed to ensure the attending physician and family were notified in a timely manner of a new open area to a resident's neck for 1 of 2 residents reviewed for notification of change in condition. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for 1 of 5 residents reviewed for bathing and hygiene care needs. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to provide bathing and/or showering care for 1 of 5 residents reviewed for bathing and hygiene care needs. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident receiving continuous enteral (gastric) feedings received feedings as ordered and a significant weight loss occurring in less than 30 days was identified and timely interventions related to the weight loss were conducted for 1 of 2 residents reviewed for gastric feedings. (Resident G)

Inspectors wroteBased on interview and record review, the facility failed to thoroughly document information regarding the identification of a newly identified open area and information regarding notification of a change in condition to the family regarding the new open area for 1 of 2 residents reviewed for tracheostomies (trach). (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This had the potential to affect 49 of 49 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to hold food on a steam table at safe temperatures with the potential to affect 48 of 49 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications and collect urine samples as ordered, to timely schedule a follow-up appointment for a resident who was admitted with a healing leg fracture, and timely implement dietary recommendations for a resident with a feeding tube for 1 of 1 resident reviewed for mobility, 1 of 1 resident reviewed for feeding tubes, and 3 of 5 residents reviewed for unnecessary medications. (Resident 11, Resident 29, Resident 30, Resident 42, and Resident 95)

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 of 5 residents medical records included documentation that indicated the resident or resident representative was provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine; whether the COVID-19 vaccine was administered to the resident; or whether the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal for 4 of 5 residents reviewed for COVID-19 immunization. (Residents 11, 18, 20, 24, and 30)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's dignity was maintained by not sitting down while assisting a resident with eating for 1 of 1 resident randomly observed during dining. (Resident 2)

Inspectors wroteBased on interview and record review, the facility failed to timely address a resident's grievance for 1 of 1 resident reviewed for choices. (Resident 11)

Inspectors wroteBased on interview and record review, the facility failed to submit to Centers for Medicare and Medicaid Services (CMS) accurate direct care staffing information regarding the correct category of work for a Registered Nurse for 49 of 49 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 4 of 7 residents reviewed for MDS accuracy (Resident 1, 12, 22, and 42).

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was correctly completed, related to falls for 1 of 3 residents reviewed for falls. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse, resulting in crying and emotional distress for 3 of 5 residents reviewed for abuse. (Residents' 20, 37, 40)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure grievances reported were addressed that included resolutions. This had a potential to affect 6 of 6 resident council members and 1 of 1 residents reviewed for food. (Resident's 4, 13, 14, 22, 31, 35, 44)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were able to file a grievance anonymously. This had a potential to effect 48 of 48 residents that reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to timely report an allegation of abuse to the Administrator; notify a resident's representative of the initiation and progress of an abuse investigation; and include pertinent information regarding an alleged victim of an abuse allegation and ensure accurate and detailed description in their state reporting for 3 of 5 residents reviewed for abuse. (Residents 20 and 37 and 40)

Inspectors wroteBased on interview and record review, the facility failed to timely create a baseline care plan for 1 of 1 resident reviewed for care planning (Resident 200).

Inspectors wroteBased on observation, interview and record review, the facility failed to create a discharge planning care plan for a resident with a goal of returning to the community at discharge for 1 of 3 residents reviewed for discharge, to develop care plans for refusal of bathing and shampooing and a resident high risk for dehydration for 1 of 3 residents reviewed for Activities of Daily Living and 1 of 1 residents reviewed of hydration. (Resident 14 and Resident 27 and Resident 202)

Inspectors wroteBased on interview and record review, the facility failed to timely update toileting care plans for 1 of 1 resident reviewed for bladder and bowel incontinence (Resident 4).

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge need for oxygen therapy was identified and to involve the interdisciplinary team to develop a plan of treatment for discharge for 1 of 3 residents reviewed for discharge (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to provide a written discharge plan of care to a resident with a planned discharge for 1 of 3 residents reviewed for discharge (Resident B).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide bathing and hair shampooing for 1 of 3 residents reviewed for Activities of Daily Living and to timely order a toileting sling to assist a resident with toileting for 1 of 1 resident reviewed for bladder and bowel incontinence (Resident 4 and Resident 14). 1. The clinical record for Resident 14 was reviewed on 8/7/23 at 12:05 p.m. The resident's diagnosis included, but was not limited to, Alzheimer's Disease. A care plan dated 5/23/23 indicated Resident 14 was cognitively impaired. An Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 14 was cognitively impaired. A care plan dated 9/19/22 indicated Resident 14 has a preference that it was important to her to choose bathing. The intervention for bathing was the resident preferred a tub bath twice a week. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a resident's medication, as ordered, for 1 of 1 resident reviewed for pain and 1 of 6 residents reviewed for unnecessary medications, and to ensure monitoring and addressing wounds and providing skin treatment to dry skin for 1 of 1 residents reviewed for wounds. (Residents' 24, 31 and B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement residents' fall interventions for 1 of 1 resident reviewed for accidents and 1 of 6 residents reviewed for unnecessary medication. (Resident 21 and Resident 37) 1. The clinical record for Resident 37 was reviewed on 8/7/23 at 3:00 p.m. Her diagnoses included, but were not limited to, vascular dementia. She resided on the memory care unit of the facility until 6/29/23, when she moved to the upstairs unit of the facility. The 5/26/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 5, indicating she was severely cognitively impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify oxygen services for 1 of 5 residents reviewed for unnecessary medications. (Resident 3)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure psychoactive and narcotic medications were administered as ordered; review and implement a resident's individualized mental health safety plan post inpatient psychiatric stay; and adequately monitor and address a resident's ongoing behaviors resulting in increased behaviors, increased anxiety, and interference of peers' daily routine and environment for 1 of 3 residents reviewed for abuse. (Resident 45)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent for 1 of 5 residents observed during medication pass. There were 25 opportunities with 2 errors resulting in an 8 % medications error rate. The errors involved 1 resident (Resident 45) in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store controlled medication under double lock in 1 of 2 medication rooms.

Inspectors wroteBased on interview and record review, the facility failed to implement a corrective plan of action that included monitoring, tracking, evaluating effectiveness for an identified concern area, abuse. This affected 3 of 5 residents reviewed for abuse. This had a potential to effect 48 of 48 residents resided in the facility.