Inspection Reports for
The Waters of Castleton Skilled Nursing Facility

The facility was found deficient in multiple areas including medication management, care planning, vision and pain management, pharmaceutical services, food service, medical record accuracy, and infection control practices. Deficiencies were generally of minimal harm with few residents affected.

The complaint related to failure to administer prescribed medication and failure to notify the physician. The citation relates to Intake 2640237. The deficiency was substantiated with evidence from record review, interviews, and observation.

The facility failed to administer the prescribed antipsychotic medication Uzedy to Resident B on 10/16/25, did not notify the physician of the missed dose, and did not properly revise the resident's behavior care plan regarding refusal of care and medication. The medication was available but not administered, and documentation of refusals was inconsistent. Staff interventions for medication refusal were inadequate and care plans lacked appropriate interventions such as offering snacks or crushing medication with food.

This citation relates to Complaint IN00457282.

The facility failed to implement timely fall interventions for a resident after a fall, did not ensure narcotic and IV antibiotic medications were administered as ordered for two residents, and failed to conduct gradual dose reductions for psychotropic medications, abruptly discontinuing them for one resident.

Complaint IN00457282 was investigated with federal and state deficiencies cited at tags F689, F755, and F758 related to fall interventions, medication administration, and psychotropic medication management.

The facility was found deficient in timely implementation of fall interventions for one resident, proper administration and availability of narcotic medications and IV antibiotics for two residents, and failure to conduct gradual dose reduction when discontinuing psychotropic medications for one resident.

The inspection was complaint-driven, related to complaints IN00451947, IN00456622, and IN00450054, involving residents' rights, notification failures, care planning, bathing care, enteral feeding, and documentation issues. The complaints were substantiated with findings of minimal harm affecting a few residents.

The facility was found deficient in honoring residents' dignity and timely response to call lights, notifying physicians and families of significant weight loss and new wounds, developing comprehensive care plans, providing bathing and hygiene care as scheduled, ensuring continuous enteral feedings, and documenting changes in condition and notifications properly. All deficiencies were cited with minimal harm and affected a few residents.

The investigation was triggered by complaints IN00450054, IN00451947, and IN00456622. Deficiencies related to dignity and call light response, notification of changes, and wound documentation were substantiated.

The facility was found deficient in timely response to call lights and dignity for residents, failure to notify family and physician timely of significant changes including weight loss and new wounds, failure to develop and implement comprehensive care plans for ADLs, failure to provide bathing and hygiene care per resident preferences, failure to maintain nutrition and hydration status for a resident receiving enteral feedings, and failure to document wound identification and notification properly.

The facility was found not in compliance with several Life Safety Code requirements including failure to replace battery-operated smoke alarms in resident rooms, failure to maintain sprinkler systems, incomplete fire drill documentation, malfunctioning rolling steel fire doors, failure to properly exercise the emergency generator, and improper use of extension cords as substitutes for fixed wiring.

This citation relates to Complaints IN00433065 and IN00428580. Deficiencies were cited related to these complaints, including failure to maintain resident dignity and failure to have RN coverage.

The facility was found deficient in multiple areas including resident dignity during feeding, grievance handling, MDS assessment accuracy, medication administration, RN coverage, food temperature safety, payroll staffing data accuracy, and COVID-19 immunization documentation.

This citation relates to Complaints IN00433065 and IN00428580.

The facility failed to have a Registered Nurse on duty for at least eight consecutive hours a day, seven days a week, potentially affecting all 49 residents. Payroll and schedule reviews confirmed no RN coverage on specific dates in April 2024.

This inspection relates to complaints IN00433065 and IN00428580. The complaints involved issues with resident dignity, grievance handling, staffing, medication administration, and COVID-19 vaccination documentation.

The facility was found deficient in maintaining resident dignity during feeding assistance, timely addressing resident grievances, accurately coding MDS assessments, administering medications and collecting urine samples as ordered, ensuring RN coverage, maintaining safe food temperatures, submitting accurate staffing data to CMS, and documenting COVID-19 vaccination education and status for residents.

Complaint IN00419427 was substantiated with a federal/state deficiency cited at F641. Complaint IN00426071 had no deficiencies related to the allegations.

The facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed related to falls for 1 of 3 residents reviewed (Resident B). The admission MDS assessment did not reflect two falls sustained by Resident B prior to the assessment reference date.

This Federal deficiency relates to Complaint IN00419429.

The facility failed to ensure an accurate MDS assessment for one of three residents reviewed for falls. Specifically, Resident B's admission MDS assessment did not reflect two falls that occurred prior to the assessment reference date.

The facility was found not in compliance with multiple Life Safety Code and regulatory requirements including emergency preparedness, fire safety, fire alarm system maintenance, sprinkler system maintenance, fire drills, and door egress requirements.

Complaint IN00411900 triggered the investigation focusing on care planning, discharge planning, activities of daily living, medication administration, and wound care.

The facility failed to timely create baseline care plans, develop complete care plans addressing resident needs including refusals and hydration, ensure discharge planning and communication, provide adequate bathing and toileting assistance, and administer medications as ordered. Monitoring and treatment of wounds and skin conditions were also inadequate.

The complaint investigation revealed multiple allegations including verbal and sexual abuse, medication errors, failure to provide care plans, and inadequate behavioral health care. Some abuse allegations were substantiated, including verbal abuse by staff and sexual abuse by a resident roommate. The facility failed to timely report abuse and notify families. Medication errors and care planning deficiencies were also identified.

The facility was found deficient in multiple areas including failure to address resident grievances, failure to ensure residents could file grievances anonymously, verbal and sexual abuse incidents, failure to timely create baseline and discharge care plans, failure to provide care plans for refusals and hydration risk, medication administration errors, failure to implement fall prevention interventions, failure to clarify oxygen therapy orders, and failure to provide adequate behavioral health care and monitoring.

Complaint IN00411900 - Federal/State deficiencies related to allegations of abuse, grievance handling, medication errors, and care planning.

The facility was found deficient in multiple areas including failure to address resident grievances, failure to issue Notices of Medicare Non Coverage, failure to allow anonymous grievance filing, verbal and sexual abuse incidents, failure to timely create baseline care plans, failure to develop discharge plans, failure to update care plans for refusals and dehydration risk, medication administration errors, failure to store controlled medications properly, failure to monitor and address resident behaviors, and deficiencies in staff training and personnel records.

This Federal tag relates to Complaint IN00410707.

The facility failed to provide timely and continued treatment for pressure ulcers for 2 of 3 residents reviewed and failed to implement follow-up instructions to change a tracheostomy every 2 weeks for 1 of 2 residents reviewed.

Complaint IN00406374 and IN00407853 had no deficiencies related to the allegations. Complaint IN00410707 had federal/state deficiencies cited at F686 (pressure ulcer treatment) and F695 (respiratory/tracheostomy care).

The facility was found deficient in providing timely and continued treatment for pressure ulcers for 2 of 3 residents reviewed, and failed to implement follow-up instructions for tracheostomy care for 1 of 2 residents reviewed. Deficiencies were cited related to pressure ulcer treatment and respiratory/tracheostomy care.

This Federal tag relates to Complaint IN00404639. The complaint involved concerns about missing personal property and inadequate room cleanliness, specifically floor care.

The facility failed to ensure complete and accurate documentation of a resident's personal property and failed to maintain residents' rooms in a clean manner, specifically regarding floor care for 2 of 5 residents reviewed.

Complaint IN00404639 was substantiated with federal/state deficiencies cited at F921 and F842. Complaints IN00398885 and IN00392443 were not substantiated with no deficiencies related to the allegations cited.

The facility was found deficient in maintaining complete and accurate resident records for personal property and in ensuring residents' rooms were maintained in a clean manner regarding floor care for two residents. Specifically, Resident L's personal property inventory was incomplete, and rooms of Residents B and K were not cleaned adequately.