Castle Hills Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Castle Hills Rehabilitation and Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF580Mar 16, 2024

  42031 Based on interview and record review the facility failed to immediately consult with the resident's physician when there was a change in condition and a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 4 of 11 residents (Residents #1, #2, #3, #4), reviewed for physician notification, in that: Residents #1-#4 were administered blood pressure medications when their blood pressures were low and outside of the physician ordered parameters without physician notification prior to or after medication administration. This failure could result in decreased continuity of care, and a delay in needed treatment and services. […]

• Immediate jeopardy, patternF760Mar 16, 2024

  42031 Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 4 of 11 residents (Residents #1, #2, #3, #4), reviewed for significant medication errors, in that: Residents #1, #2, #3, and #4 were administered medications to lower blood pressures when their blood pressures or Pulse was already low and outside the physician ordered parameters. An immediate jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:23 p.m. […]

• Immediate jeopardy, isolatedF689Sep 12, 2025

  Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 15 residents (Resident#74) reviewed for accident hazards and supervision. Resident #74 eloped at night and crossed a busy 5-lane road before she was found at a bus stop by an off-duty CNA. This failure resulted in the identification of an IJ (Immediate Jeopardy) on 09/10/25. While the immediacy was removed on 09/12/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal This failure could place residents at risk for… […]

• Immediate jeopardy, isolatedF655May 2, 2025

  Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the residents that meets professional standards of quality of care within 48 hours of a resident's admission for one (Resident #1, of five residents reviewed for baseline care plans, in that: The facility failed to implement Resident #1's baseline care plan and failed to include Resident #1's current urinary tract infection and antibiotic use in the baseline care plan resulting in Resident #1's hospitilization with a diagnosis of sepsis. […]

• Immediate jeopardy, isolatedF690May 2, 2025

  Based on interview and record review the facility failed to ensure that residents with indwelling catheters received appropriate treatment and services for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to manage Resident #1's foley catheter by not having orders for catheter care, monitoring for signs/symptoms of infection, or monitoring the input/output, subsequently leading to hospitalization on 03/12/25 and a diagnosis of sepsis. These failures could place Residents with indwelling urinary catheters at risk of discomfort, infections, and a decreased quality of life, and hospitalization. An IJ was identified on 04/29/25. The IJ template was provided to the facility on [DATE] at 9:37 pm. […]