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Deficiency Records for The Waters of Castleton Skilled Nursing Facility

View the most recent health deficiencies and inspection results for The Waters of Castleton Skilled Nursing Facility. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for The Waters of Castleton Skilled Nursing Facility. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-12-16 2026-05-31 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2026-03-11 2026-04-07 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2026-03-11 2026-04-07 Y
Respond appropriately to all alleged violations. Health 2026-03-11 2026-04-07 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2026-03-11 2026-04-07 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2026-03-11 2026-04-07 Y
Assist a resident in gaining access to vision and hearing services. Health 2025-12-16 2026-01-19 N
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Health 2025-12-16 2026-01-19 N
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Health 2025-12-16 2026-01-19 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2025-12-16 2026-01-19 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2025-12-16 2026-01-19 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2025-12-16 2026-01-19 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2025-12-16 2026-01-19 N
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Health 2025-12-16 2026-01-19 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2025-12-16 2026-01-19 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2025-12-16 2026-01-19 N
Provide and implement an infection prevention and control program. Health 2025-12-16 2026-01-19 N
Provide properly protected cooking facilities. Fire Safety 2025-12-16 2026-01-17 N
Meet other general requirements. Fire Safety 2025-12-16 2026-01-17 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2025-10-28 2025-11-21 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-04-16 2025-05-09 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2025-04-16 2025-05-09 Y
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. Health 2025-04-16 2025-05-09 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-04-02 2025-04-25 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2025-04-02 2025-04-25 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2025-04-02 2025-04-25 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2025-04-02 2025-04-25 Y
Provide enough food/fluids to maintain a resident's health. Health 2025-04-02 2025-04-25 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2025-04-02 2025-04-25 Y
Meet other general requirements that are deficient. Fire Safety 2024-10-08 2024-11-08 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-10-08 2024-11-08 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-10-08 2024-11-08 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-10-08 2024-11-08 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-10-08 2024-11-08 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-10-08 2024-11-08 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-10-08 2024-10-26 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2024-10-08 2024-10-26 Y
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2024-10-08 2024-10-26 N
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Health 2024-10-08 2024-10-26 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-10-08 2024-10-26 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-10-08 2024-10-26 N
Ensure each resident receives an accurate assessment. Health 2024-10-08 2024-10-26 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2024-10-08 2024-10-26 N
Ensure each resident receives an accurate assessment. Health 2024-01-25 2024-02-11 Y
Provide properly protected cooking facilities. Fire Safety 2023-08-11 2023-09-22 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2023-08-11 2023-09-22 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2023-08-11 2023-09-22 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-08-11 2023-09-22 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-08-11 2023-09-22 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-08-11 2023-09-22 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-08-11 2023-09-22 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-08-11 2023-09-22 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-08-11 2023-09-22 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-08-11 2023-09-22 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-08-11 2023-09-22 N
Meet other general requirements that are deficient. Fire Safety 2023-08-11 2023-09-22 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-08-11 2023-09-22 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2023-08-11 2023-09-22 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2023-08-11 2023-09-22 N
Implement emergency and standby power systems. Fire Safety 2023-08-11 2023-09-22 N
Conduct testing and exercise requirements. Fire Safety 2023-08-11 2023-09-22 N
Establish staff and initial training requirements. Fire Safety 2023-08-11 2023-09-22 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-08-11 2023-09-22 N
Ensure medication error rates are not 5 percent or greater. Health 2023-08-11 2023-09-05 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2023-08-11 2023-09-05 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2023-08-11 2023-09-05 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2023-08-11 2023-09-05 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-08-11 2023-09-05 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2023-08-11 2023-09-05 Y
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2023-08-11 2023-09-05 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-08-11 2023-09-05 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-11 2023-09-05 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2023-08-11 2023-09-05 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-08-11 2023-09-05 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-08-11 2023-09-05 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-08-11 2023-09-05 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-08-11 2023-09-05 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-08-11 2023-09-05 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2023-08-11 2023-09-05 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2023-08-11 2023-09-05 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-06-20 2023-07-09 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-06-20 2023-07-09 Y

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