Mission at Castle Rock

In the surveyor’s words

From the most serious findings on record at Mission at Castle Rock, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Oct 6, 2022

  Based on observation, staff interview, and review of the U.S. Public Health Service Food Code, the facility failed to ensure food was properly stored in 1 of 1 kitchen. In addition the facility failed to ensure proper hand hygiene during food preparation during 1 of 1 meal preparation observation. The census was 44. The findings were: 1. Observation on 10/3/22 at 2:15 PM and again on 10/5/22 at 8:45 AM showed a portable ice cream cart with 8 varieties of ice cream was located in the main kitchen. There was no evidence the temperature of the ice cream cart had been monitored. Interview with the CDM on 10/5/22 at 10:20 AM revealed the cart was used every Wednesday for an ice cream social with the residents. Further the CDM confirmed the temperature of the cart was not monitored. 2. […]

• No harm, potential for more than minimal, widespreadF801Oct 7, 2021

  Based on staff interview and employee training review, the facility failed to ensure the dietary manager was qualified. The census was 47. The following concerns were identified: 1. Interview with the dietary manager on 10/7/21 at 9:35 AM revealed she had completed the certified dietary manager course through an approved program; however, she had not completed the certification exam at that time. 2. Review of training certificate showed the dietary manager completed the Nutrition & Foodservice Professional Training Program on 4/27/21.

• No harm, potential for more than minimal, widespreadF812Oct 7, 2021

  Based on observation, staff interview, policy and procedure review, and review of food code reference, the facility failed to ensure a sanitary environment was maintained during 1 of 2 meal services observed (10/6/21 mid-day meal). The census was 47. The findings were: 1. Observation of meal service on 10/6/21 at 11:38 AM showed dietary aide #1 left the service line with his gloves on, touched the exterior of the walk-in cooler door with both hands, removed a dessert cart from the cooler, used both hands to push the cart near the service line, and returned to the service line. The dietary aide removed lids from pre-poured drink glasses and grabbed the glasses by the rim, then placed the glasses on resident trays. […]

• No harm, potential for more than minimal, patternF761Jan 19, 2024

  Based on observation, staff interview, policy and procedure review, and professional standard review, the facility failed to ensure medications were labeled in accordance with professional standards in 1 of 3 medication storage units (back hall medication cart). The findings were: 1. Observation on 1/17/24 at 1:52 PM of the back hall medication cart, showed 1 Humalog 100 unit/ml vial with no open date, and 1 Humalog 100 unit/ml Kwik pen dated 11/29/23. Interview at that time with MA-C #1 confirmed the medications were for resident use. Further, the MA stated the medication should be dated when opened. She confirmed the insulins should only be used for 28 days or 1 month. 2. […]

• No harm, potential for more than minimal, patternF948Oct 6, 2022

  Based on review of facility records and staff interview, the facility failed to ensure paid feeding assistants had completed a State-approved training program. The facility had 10 residents which required assistance with eating and utilized 4 feeding assistants (FA #1, FA #2, FA #3, FA #4). The findings were: 1. Review of the facility's records showed 4 feeding assistants had been trained by the facility using a Feeding Assistant Check-Off form. FA #1 was trained on 1/25/22, FA #2 was trained on 7/28/22, FA #3 was trained on 8/20/22, and FA #4 was trained on 9/27/22. 2. Interview with the NHA on 10/4/22 at 4:47 PM confirmed the facility had not used a State-approved training program for training feeding assistants.