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Deficiency Records for Castleton Health Care Center
A list of the most recent deficiencies for Castleton Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Castleton Health 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Develop a communication plan. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-09-30 | 2024-10-14 | 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 | 2024-09-30 | 2024-10-14 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-30 | 2024-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-13 | 2024-09-23 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-09-13 | 2024-09-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-09-13 | 2024-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-13 | 2024-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-13 | 2024-09-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-09-13 | 2024-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-10 | 2024-02-22 | 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 | 2023-10-30 | 2023-11-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-30 | 2023-11-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-30 | 2023-11-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-30 | 2023-11-16 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-29 | 2023-10-24 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-29 | 2023-10-24 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-29 | 2023-10-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-29 | 2023-10-24 | 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 | 2023-09-29 | 2023-10-24 | N |
| Post nurse staffing information every day. | Health | 2023-09-29 | 2023-10-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-29 | 2023-10-24 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-09-29 | 2023-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-29 | 2023-10-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-29 | 2023-10-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-29 | 2023-10-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-29 | 2023-10-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-29 | 2023-10-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-29 | 2023-04-21 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-29 | 2023-04-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-29 | 2023-04-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-29 | 2023-04-21 | Y |
| Provide appropriate foot care. | Health | 2023-03-29 | 2023-04-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-29 | 2023-04-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-29 | 2023-04-21 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-04-22 | 2022-06-25 | N |
| Meet other general requirements. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-31 | 2022-06-13 | 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 | 2022-05-31 | 2022-06-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-05-31 | 2022-06-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-01 | 2022-06-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-01 | 2022-06-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-22 | 2022-06-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-04-22 | 2022-05-20 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-04-22 | 2022-05-20 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-22 | 2022-05-20 | 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 | 2022-04-22 | 2022-05-20 | 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 | 2022-04-22 | 2022-05-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-22 | 2022-05-20 | N |
| 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 | 2022-04-22 | 2022-05-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-22 | 2022-05-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-22 | 2022-05-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-22 | 2022-05-20 | 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 | 2022-04-22 | 2022-05-20 | 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 | 2022-04-22 | 2022-05-20 | N |
| Provide or obtain dental services for each resident. | Health | 2022-04-22 | 2022-05-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-22 | 2022-05-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-27 | 2022-02-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-27 | 2022-02-09 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-27 | 2022-02-09 | Y |
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