Deficiency Records for The Waters of Castleton Skilled Nursing Facility
Updated as of March 01, 2024
A list of the most recent deficiencies for The Waters of Castleton Skilled Nursing Facility. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-29 | 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 | 2023-08-29 | 2023-09-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-08-29 | 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 | 2023-08-29 | 2023-09-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-29 | 2023-09-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-29 | 2023-09-22 | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-11 | 2023-09-05 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-11 | 2023-09-05 | 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-20 | 2023-07-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-20 | 2023-07-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-12 | 2023-05-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-12 | 2023-05-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-05 | 2022-05-06 | Y |
| Meet other general requirements. | Fire Safety | 2022-03-21 | 2022-04-08 | 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 | 2022-03-21 | 2022-04-08 | 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 | 2022-03-21 | 2022-04-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-21 | 2022-04-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-21 | 2022-04-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-21 | 2022-04-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-21 | 2022-04-08 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-03-21 | 2022-04-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-21 | 2022-04-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-21 | 2022-04-08 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-03-21 | 2022-04-08 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-21 | 2022-03-07 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-02-21 | 2022-03-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-21 | 2022-03-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-21 | 2022-03-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-21 | 2022-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-21 | 2022-03-07 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-02-21 | 2022-03-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-21 | 2022-03-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2021-12-20 | 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 | 2021-12-09 | 2021-12-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-09 | 2021-12-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-05 | 2021-11-12 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-10-26 | 2021-11-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-26 | 2021-11-10 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-15 | 2021-09-24 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-03-23 | 2021-03-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-23 | 2021-03-28 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-19 | 2020-01-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-19 | 2020-01-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-12-19 | 2020-01-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-19 | 2020-01-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-19 | 2020-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-19 | 2020-01-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-27 | 2019-10-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-27 | 2019-10-22 | 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 | 2019-09-27 | 2019-10-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-27 | 2019-10-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-27 | 2019-10-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-27 | 2019-10-22 | N |
| Provide appropriate foot care. | Health | 2019-09-27 | 2019-10-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-09-27 | 2019-10-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-27 | 2019-10-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-27 | 2019-10-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-27 | 2019-10-22 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-09-27 | 2019-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-27 | 2019-10-22 | N |
