Castle Pines Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Castle Pines Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Jul 9, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689May 14, 2026

  Based 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.Findings included: Record review of the electronic face sheet indicated Resident #1 was a [AGE] year old male originally admitted to the facility on… […]

• Immediate jeopardy, isolatedF689Mar 26, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Sep 28, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2024

  Based 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. Findings include: During an observation and interview on [DATE] at 9:15 AM the refrigerator contained a plastic container of a thickened white liquid and a large square plastic container with a red lid that had a gelatin type substance inside that was not dated. […]