Castleton Health Care Center

In the surveyor’s words

From the most serious findings on record at Castleton Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 23, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident at risk for developing pressure ulcers and identified with redness to the right heel upon admission to the facility, had thoroughly completed skin assessments and identification of risk factors to where the resident (Resident BB) complained of pain and was identified with a stage (3) three pressure ulcer (full-thickness skin loss, penetrated through the top two layers of skin and into the fatty tissue beneath) that required ongoing treatment for 1 of 3 residents reviewed for quality of care. (Resident BB)Findings include: The clinical record for Resident BB was reviewed on 9/19/25 at 2:10 p.m. […]

• Actual harm, isolatedF684Sep 29, 2023

  Based on observation, interview, and record review, the facility failed: to provide routine suprapubic catheter care and to provide routine nephrostomy tube care to a resident, resulting in a hospitalization for sepsis, acute kidney injury, and UTI (urinary tract infection) associated with his nephrostomy catheter for 1 of 3 residents reviewed for urinary catheter care (Resident 36); and ensure the residents' medications were administered as ordered for 2 of 6 residents reviewed for unnecessary medications (Resident 23 and Resident 32). Findings include: 1. The clinical record for Resident 36 was reviewed on 9/26/23 at 2:00 p.m. His diagnoses included, but were not limited to: metastatic prostate cancer, bladder cancer, deep vein thrombosis, type 2 diabetes, and hypertension. […]

• Actual harm, isolatedF690Apr 22, 2022

  Based on observation, interview, and record review, the facility failed to coordinate care to address a resident's continued use of a Foley catheter resulting in the resident developing a urinary tract infection for 1 of 1 residents reviewed for catheter care. (Resident 25) Findings include: The clinical record for Resident 25 was reviewed on 4/20/22 at 11:51 a.m. Resident 25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 25 was admitted to the facility on [DATE]. At the time of admission, Resident 25 had a Foley catheter in place. An observation of Resident 25 occurred on 4/19/22 at 11:17 a.m. Resident 25 had a Foley catheter and the drainage bag was hanging on the side of his bed. An interview with Resident 25 was conducted on 4/19/22 at 11:17 a.m. […]

• Actual harm, isolatedF697Apr 22, 2022

  Based on interview and record review, the facility failed to adequately address a resident's pain after a fall with [CONDITION(S)] resulting in continued extreme pain for 1 of 1 residents reviewed for death. (Resident 36) Findings include: The clinical record for Resident 36 was reviewed on 4/20/22 at 10:53 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was admitted to the facility on [DATE]. The 1/16/22 progress note read, Resident tested positive for covid 19, resident moved immediately with N95 into red zone precautions, MD and family notified. The 1/21/22, 10:02 p.m. nurse's note, written by the NC (Nurse Consultant) read, Resident alert to self with moderate to severe confusion. Severe tremors in all extremities. Unable to hold drink or use eating utensils. […]

• Actual harm, isolatedF689Jan 27, 2022

  Based on interview and record review, the facility failed to determine motor ability, fully conduct neurological check assessments, and identify pain after a fall that resulted in a femur fracture for 1 of 3 residents reviewed for falls. (Resident C) Finding include: The clinical record for Resident C was reviewed on 1/26/2022 at 11:22 a.m. The clinical diagnoses included, but were not limited to, dementia without behavioral disturbances, cachexia, [CONDITION(S)], and muscle weakness. A Quarterly Minimum Data Set, dated dated [DATE], indicated that Resident C was cognitively impaired, needed staff assistance with activities of daily living, and had multiple falls without injury. […]