Waters of Castleton Skilled Nursing Facility, The

In the surveyor’s words

From the most serious findings on record at Waters of Castleton Skilled Nursing Facility, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Mar 23, 2021

  Based on record review and interview, the facility failed to ensure residents were provided care and services to prevent the development of pressure ulcers in the facility. One resident, who developed pressure ulcers to the bilateral heels after admission, developed infection and required hospitalization and emergency surgery, ultimately resulting in an above the knee amputation (Resident B), and another resident developed unstageable pressure ulcers to the heels after admission and required ongoing treatment (Resident C), for 2 of 5 residents reviewed for pressure ulcers. The Immediate Jeopardy began on 12/09/20, when the facility failed to implement pressure relief interventions to prevent pressure ulcers to the heels of Resident B, who was admitted without pressure ulcers. […]

• Actual harm, isolatedF600Aug 11, 2023

  Based on interview and record review, the facility failed to ensure residents were free from abuse, resulting in crying and emotional distress for 3 of 5 residents reviewed for abuse. (Residents' 20, 37, 40) Findings include: 1. The clinical record for Resident 37 was reviewed on [DATE] at 3:00 p.m. Her diagnoses included, but were not limited to, vascular dementia. She resided on the memory care unit of the facility until [DATE]. The [DATE] Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 5, indicating she was severely cognitively impaired. The [DATE], 7:18 p.m. nurses note, recorded as a late entry on [DATE], read, Writer notified sister [name of sister] and provider about the incident that occurred same day. […]

• No harm, potential for more than minimal, widespreadF727Oct 8, 2024

  Based on interview and record review, the facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This had the potential to affect 49 of 49 residents in the facility. Findings include: The Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of the 2024 Federal Fiscal Year indicated the facility had no RN coverage hours on the following dates: 4/7/24, 4/20/24, 4/21/24, 5/4/24, 5/5/24, 5/18/24, 5/19/24, 5/27/24, 6/1/24, 6/2/24, 6/15/24, 6/16/24, and 6/30/24. On 10/3/24 at 10:20 a.m., the Administrator provided the Daily Nursing Schedule for the above dates. […]

• No harm, potential for more than minimal, widespreadF812Oct 8, 2024

  Based on observation, interview, and record review, the facility failed to hold food on a steam table at safe temperatures with the potential to affect 48 of 49 residents residing at the facility. Findings include: On 10/4/24 at 12:41 p.m., the lunch service was observed in the facility's main kitchen with Facility [NAME] (FC) 1. FC 1 indicated he was serving the room trays. The steam table contained a serving pan of mixed vegetables and a serving pan of [NAME] fish filets. The temperature of the mixed vegetables was obtained at 121.8 degrees Fahrenheit (F). The temperature of the [NAME] fish fillets was obtained at 107 degrees F. FC 1 indicated the temperature of the mixed vegetables, and the [NAME] fish filets should have been at least 135 degrees F. […]

• No harm, potential for more than minimal, widespreadF812Feb 21, 2022

  Based on observation, record review, and interview, the facility failed to ensure food was stored and prepared under sanitary conditions related to: foods not in original containers not clearly labeled for contents, dated, or stored with tight fitting lids; storing food at least 6 inches off floor; storing dish racks on ground; not labeling, dating, and/or covering items in coolers or freezer; and not ensuring foods are not expired, for 68 of 69 residents served meals from the kitchen. Findings include: A brief kitchen tour was conducted with DM (Dietary Manager) 2 on [DATE] at 10:27 a.m. During the kitchen tour, the following was observed: In the dry goods room: - A large plastic container containing a white substance was located on the floor. DM 2 identified it as sugar. […]