Deficiency Records for Castle Hills Rehabilitation and Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Castle Hills Rehabilitation and Care Center. 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? |
|---|---|---|---|---|
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-12-21 | 2024-01-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Meet other general requirements. | Fire Safety | 2023-07-12 | 2023-08-25 | 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 | 2023-07-12 | 2023-08-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-12 | 2023-08-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-14 | 2023-08-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-14 | 2023-08-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-07-14 | 2023-08-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-14 | 2023-08-14 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-07-14 | 2023-08-14 | N |
| Dispose of garbage and refuse properly. | Health | 2023-07-14 | 2023-08-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-14 | 2023-08-14 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-14 | 2023-07-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-14 | 2023-07-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-14 | 2023-07-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-14 | 2023-07-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-12 | 2023-07-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-12 | 2023-07-13 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-07-10 | 2023-07-12 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-10 | 2023-07-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-10 | 2023-07-11 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-07-10 | 2023-07-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-10 | 2023-07-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-29 | 2023-07-05 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-06-29 | 2023-07-05 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-04-24 | 2023-04-25 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-04-18 | 2023-04-25 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-18 | 2023-04-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-18 | 2023-04-21 | Y |
| Post nurse staffing information every day. | Health | 2023-04-18 | 2023-04-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-18 | 2023-04-19 | Y |
| Have an externally vented heating system. | Fire Safety | 2022-06-10 | 2022-07-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-10 | 2022-07-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-10 | 2022-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-10 | 2022-07-15 | 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 | 2022-06-10 | 2022-07-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-06-10 | 2022-07-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-10 | 2022-07-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-10 | 2022-07-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-10 | 2022-07-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-10 | 2022-07-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-10 | 2022-07-11 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-06-10 | 2022-07-11 | 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 | 2022-06-10 | 2022-07-11 | 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 | 2022-06-10 | 2022-07-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-10 | 2022-07-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-06-10 | 2022-07-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-10 | 2022-06-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-10 | 2022-06-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-13 | 2022-05-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-13 | 2022-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-10 | 2021-06-14 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-10 | 2021-04-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-10 | 2021-04-09 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-03-12 | 2021-04-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-12 | 2021-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-12 | 2021-03-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-12 | 2021-03-24 | 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 | 2021-03-12 | 2021-03-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-03-12 | 2021-03-21 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-03-12 | 2021-03-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-12 | 2021-03-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-03-10 | 2021-03-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-03-10 | 2021-03-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-10 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-10 | Not Fixed | N |
