Castle Peak Senior Life and Rehabilitation

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Smoke Deficiencies

Install properly constructed windows in hallway walls or doors.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Egress Deficiencies

Have exits that are accessible at all times.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Based on record review and interviews, the facility failed to ensure compliance with secure environment requirements for three (#1) of three residents reviewed for secure unit placement out of five sample residents. Specifically, the facility failed to ensure the designated team who was responsible for evaluating the placement of Resident #1 in a secured environment included an independent reviewer who was not a facility staff member. Findings include:.. Based on record review and interviews, the facility failed to ensure components of a secured placement was met for one (#1) of three residents reviewed out of five sample residents. Specifically, the facility failed to ensure Resident #1' s representative had given informed, written consent for Resident #1 to be placed on the secured memory care unit. Findings include:.. *** CITATION TEXT NOT FOUND *** A survey prompted by complaint #CO40519 was completed on 6/16/25 to 6/18/25. Two deficiencies were cited. .. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Based on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints for one (#1) of three residents out of five sample residents. Specifically the facility failed to: -Ensure Resident #1 had physician' s orders for the placement of a wanderguard; and, -Obtain consent to move Resident #1 to the secured unit, which prevented the resident from activities that met his interests. Findings include: I. Facility policy and procedure .. *** CITATION TEXT NOT FOUND *** A complaint survey, prompted by #CO39979, Incident #39980 and Incident #40435 was conducted on 6/16/25 to 6/18/25. One deficiency was cited.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics. This facility is a two-story Type II (111) 33,460 Sqft structure licensed for forty-four (44) reside.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:1) Fire Alarm Annual: 7.1.24 Johnson Control, 7 deficiencies found during inspection need correctedNFPA 101 18.3.4.1 Health care occupancies shall be pr.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 80. This was evidenced by: 1) Fire Doors (annually)(80 5.2): This is not provided for all doors; it is provided for 3 drop doors.NFPA 101, 8.3.3.1 Openings required to have a fire protection r.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80, 90A, and 105. This was evidenced by:1) The Fire Dampers report shows 13 failed devices; only have paperwork showing 8 have been corrected and 3 have been removed. There is no eviden.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Emergency Power Battery Testing(Monthly specific gravity,weekly voltage)(110 8.3.7): Not ProvidedNFPA 110 8.3.7 Storage batteries, including .. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Emergency Lighting (Monthly & Annual)(101 7.9.3.1.1): Monthly provided, No annual 90 minute providedNFPA 101 7.9.3.1.1 Testing of required emergency lightin.. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101 and 70. This was evidenced by:1) remove or safe off with approved enclosure, abandoned electrical wire on the first-floor mini kitchenNFPA 1019.1.2 Electrical Systems. Electrical wiring and equipment shall .. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) oxygen trans filling rooms (1st and 2nd floor) need ventilation 0-12" from the floor2) Remove the transfer grill from both trans-filling rooms; the transfer grill is compro.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Remove the combustible Christmas tree from the facility found in the storage closet NFPA 101 18.7.5.6 Combustible decorations shall be prohibited in any health care occupancy, u.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) remove the transfer grills from both oxygen trans-filling rooms (1st and 2nd floor)NFPA 101 18.3.6.4 Transfer Grilles.18.3.6.4.1 Transfer grilles, regardless of whether they are prot..

A licensure survey was completed on 9/16/24 to 9/19/24. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure two (#10 and #35) of five residents out of 23 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being.Resident #10 was admitted to the facility for long-term care on 4/6/18 with diagnoses of dementia, stroke, and seizure disorder. Upon admission, the resident weighed 117 pounds (lbs). On 7/30/24, Resident #10 weighed 145.6 lbs. On 9/3/24 the resident weighed 126 lbs. Resident #10 sustained a 18.6 lbs (12.8%) weight loss from 7/30/24 to 8/27/24 in one month, which was considered severe weight loss.Due to the facility' s failure to accurately assess and implement nutrition interventions timely the resident' s weight continued to decline.. Additionally, Resident #35 admitted on 4/18/24 with a diagnosis of gastroesophageal reflux disease (GERD), arthritis and thyroid disorder. Upon admission, the resident weighed 107 lbs. On 8/1/24 the facility discontinued the oral nutritional supplement that was prescribed to the resident, due to weight gain. However, the resident had lost 1.6 lbs from 7/23/24 to 7/30/24, in one week. The resident continued to have gradual weight loss and on 9/10/24 the resident weighed 106 lbs, which indicated the resident had lost eight pounds (7%) from 8/6/24 to 9/10/24, in one month, which was considered severe. After the resident sustained severe weight loss, the facility failed to implement person centered nutritional interventions to address the weight loss. Findings include:I. Facility policy and procedureThe weight measurement policy, reviewed 3/28/24, was provided by the nursing home administrator (NHA) on 9/19/24 at 1:12 p.m. It documented in pertinent part,"Weigh the resident at approximately the same time of day."A re-weigh is needed in these circumstances: if the present weight of the resident is plus or minus five pounds from the previous weight, or if the resident weighs 100 pounds or less and the present weight is plus or minus three p..