Castle Peak Senior Life and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Castle Peak Senior Life and Rehabilitation, in the surveyor’s own words.

• Actual harm, patternF725Jun 14, 2021

  Based on interviews, observations and record review, the facility failed to provide sufficient nursing staff to ensure resident care needs were met in keeping with their comprehensive plans of care. The failure to provide sufficient nursing staffing contributed to residents experiencing incontinence, inadequate pain management, unsafe transfer assistance, abuse, and inadequate dementia care. Cross-reference F550, dignity and respect. The facility failed to respond in a timely manner to Resident #7's requests for assistance to the bathroom, resulting in incontinence accidents, discomfort and a rude staff response after an incontinence episode. […]

• Actual harm, isolatedF689Mar 10, 2026

  Based 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. […]

• Actual harm, isolatedF692Sep 19, 2024

  Based 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. […]

• Actual harm, isolatedF600Dec 2, 2021

  Based 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. Findings include: I. […]

• Actual harm, isolatedF692Dec 2, 2021

  Based 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. […]