Inspection Reports for
Castle Peak Senior Life and Rehabilitation

The complaint investigation found that Resident #1 was involuntarily discharged due to behavioral issues without reassessment after hospital stabilization. The facility did not assist in finding an alternate facility and left the resident in hospital care unnecessarily. The complaint was substantiated based on record review and interviews.

The facility failed to allow Resident #1 to return after an unplanned hospital discharge, did not provide required physician documentation regarding unmet resident needs, and failed to reassess the resident for readmission after stabilization. Interviews and record reviews confirmed the resident was involuntarily discharged due to behavioral issues without proper reassessment or discharge summary documentation.

The complaint investigation focused on Resident #1 who eloped from the facility and was subsequently placed on a wanderguard and moved to a secured memory care unit without proper physician orders or family consent. The resident's representative and power of attorney expressed concerns about the lack of personalized activities and restrictions placed on the resident.

The facility failed to ensure Resident #1 had physician's orders for the placement of a wanderguard and did not obtain consent to move the resident to the secured unit, restricting his activities. The resident was placed on the secured memory care unit without proper assessment or consent, and the wanderguard orders were incomplete or improperly entered.

The complaint investigation focused on alleged resident-to-resident abuse involving Residents #22 and #23, and included review of abuse investigation procedures, resident care plans, staff interviews, and monitoring of resident safety and behavior.

The facility failed to prevent and thoroughly investigate a resident-to-resident altercation involving slapping, and failed to implement interventions to prevent future incidents. Additionally, the facility failed to ensure timely and appropriate care related to medication administration, nutrition, psychotropic medication orders, and medication error reporting.

The investigation was complaint-driven, focusing on accident hazards and care deficiencies for residents with dementia. The complaint was substantiated with findings of inadequate fall investigation and insufficient meal assistance.

The facility failed to ensure a safe environment free from accident hazards for residents, specifically failing to conduct a thorough investigation and implement preventive measures after an unwitnessed fall for Resident #26. Additionally, the facility failed to provide appropriate treatment and meal assistance with dignity for residents diagnosed with dementia, including Residents #16 and #18.

The complaint investigation included allegations of physical abuse, failure to report abuse, failure to investigate abuse, inadequate wound care, inadequate nutritional support, inadequate fall prevention and investigation, inadequate IV care, and failure to provide appropriate psychosocial care. The facility substantiated physical abuse of Resident #9 and identified multiple failures in care and investigation for other residents.

The facility substantiated physical abuse of Resident #9 by a staff member and terminated involved staff. The facility failed to timely report and thoroughly investigate allegations of abuse for Resident #26. Resident #20 experienced significant weight loss with inadequate interventions. Resident #9 had multiple falls with incomplete investigations and care plan updates. Resident #83's IV care lacked proper maintenance and physician orders. Resident #26 had psychosocial care issues with male caregivers despite documented preferences.