A list of the most recent deficiencies for Mission at Castle Rock. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-17 | 2024-02-29 | N |
| Provide activities to meet all resident's needs. | Health | 2024-01-19 | 2024-02-16 | 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 | 2024-01-19 | 2024-02-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-19 | 2024-02-16 | 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 | 2024-01-19 | 2024-02-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-29 | 2023-12-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-13 | 2023-01-06 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-06 | 2022-12-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-06 | 2022-12-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-10-06 | 2022-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-06 | 2022-12-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-06 | 2022-12-01 | N |
| Ensure that paid feeding assistants have the training they need. | Health | 2022-10-06 | 2022-12-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-06 | 2022-12-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-06 | 2022-12-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-06 | 2022-12-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-10-06 | 2022-12-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-08 | 2022-05-06 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-10-07 | 2021-11-19 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-10-07 | 2021-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-07 | 2021-11-19 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-10-07 | 2021-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-07 | 2021-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-06 | 2021-11-16 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-10-07 | 2021-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-07 | 2021-11-05 | N |
| 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 | 2021-10-07 | 2021-10-29 | 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 | 2021-10-06 | 2021-10-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-06 | 2021-10-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-06 | 2021-10-29 | N |
