WATERS OF CASTLETON SKILLED NURSING FACILITY, THE

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 9, 2025

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 — Deficient, Provider has date of correction, corrected May 9, 2025

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 21, 2025

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 9, 2025

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 25, 2025

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 25, 2025

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 25, 2025

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 25, 2025

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 25, 2025

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 25, 2025

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2026

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2024

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.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2024

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.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2024

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2024

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2024

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2024

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 9, 2023

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 9, 2023

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 11, 2024

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Plan the resident's discharge to meet the resident's goals and needs.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 5, 2023