Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Castle Peak Senior Life And Rehabilitation during CMS and state inspections, most recent first.
A resident with cognitive impairment and documented visual deficits requested very hot tea, which a PTA dispensed from a hot beverage machine and then further heated in a microwave, contrary to facility policy prohibiting reheating of facility-provided drinks. The PTA secured a lid on the cup and placed it at the bedside. Due to visual impairment, the resident could not locate the drinking opening, attempted to remove the lid independently, and spilled the hot liquid onto an arm and thigh, sustaining second-degree partial thickness burns over approximately 6% TBSA. Nursing and NP assessments documented bright red, blanchable burns with blistering and subsequent healing, and staff interviews confirmed that the beverage had been overheated and that the resident’s visual impairment and lack of appropriate supervision and adaptive equipment contributed to the accident.
A resident with CVA-related left-sided hemiplegia, who used a wheelchair and was cognitively intact, was moved to a different room after reporting strong chemical odors and refusing to return to the original room. Facility policy stated that staff would assist with packing and unpacking belongings for room changes, and staff reported that environmental services, nursing, or maintenance typically helped move items. In this case, however, staff repeatedly told the resident they could not move her belongings and would only escort her while she attempted to move them herself, despite her physical limitations. The NHA communicated by email that, due to prior disputes about handling of personal property, the resident was responsible for arranging family or third-party movers at her own expense, while staff would only provide access and oversight. As a result, most of the resident’s personal items remained in the original room for an extended period after she agreed to the permanent room change.
A resident with a history of CVA, left-sided hemiplegia, and behavioral symptoms reported that the DON confronted her during a room-move, stood in a confrontational posture, argued with her about moving her own belongings despite her physical limitations, raised her voice, and mocked her request for written communication and her disabilities. The resident emailed the NHA with a recording and written statement, later stating she felt the DON’s behavior was verbally abusive. The NHA reviewed the recording and statements, consulted with corporate staff, and concluded the allegation was not substantiated, and therefore did not report the resident’s abuse allegation to the State Agency, contrary to the facility’s occurrence reporting policy requiring all abuse allegations to be reported within specified time frames.
A resident with CVA-related left-sided hemiparesis and a history of behavioral symptoms alleged that the DON verbally abused and mocked her during a heated argument about moving her belongings to a new room, after she had requested assistance as an accommodation and asked that communication occur in writing. The resident reported feeling cornered and provoked, provided an audio recording and written statement to the NHA, and described the DON’s behavior as verbally abusive. The DON also emailed her account of the incident, and an RN was present during the exchange. However, the facility did not document a thorough abuse investigation as required by its policy: there was no detailed interview of the resident, no documented, substantive interview of the RN, no interviews with other staff or residents, no documented review and analysis of the audio recording, and no comprehensive written investigation findings, resulting in a deficiency for failure to thoroughly investigate an abuse allegation.
A resident was transferred or discharged without the facility ensuring that their needs and preferences were met, and without adequate preparation for a safe transition.
A resident with cognitive impairment and a history of elopement was placed on a wanderguard and moved to a secured memory care unit without continuous physician orders and without obtaining consent from the resident’s representative. The resident’s opportunities for preferred activities, such as walking and going outside, were limited, and documentation of activity participation was inconsistent. Staff interviews confirmed that required orders and consent processes were not properly followed.
Two residents experienced severe weight loss due to the facility's failure to implement timely nutritional interventions. One resident with dementia lost 18.6 pounds in a month, while another with GERD and thyroid disorder lost 8 pounds. The facility discontinued nutritional supplements without addressing the weight loss, and staff interviews revealed a lack of awareness and action regarding the residents' nutritional needs.
A resident in a memory care unit slapped another resident due to a lack of personal space, and the facility failed to conduct a thorough investigation or implement timely interventions. Both residents had severe cognitive impairments, and the incident was not reported as abuse due to the lack of willful intent. However, the facility did not interview the residents or staff adequately, nor did it update care plans promptly to prevent future incidents.
A resident experienced an unwitnessed fall and the facility failed to take immediate vital signs as required by professional standards. Despite the care plan's directive, vital signs were not recorded until two days later. Staff interviews confirmed the necessity of immediate assessment, including vital signs, to ensure resident safety.
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. Both residents were prescribed Haloperidol without a stop date, and the medication was used on an as-needed basis for over 14 days without proper documentation. The medical director and director of nursing acknowledged the error, noting that as-needed psychotropic medications should have a maximum prescribing time of 14 days.
A resident with otitis externa did not receive prescribed cortisporin ear drops due to a delay in delivery from an out-of-town pharmacy. The resident experienced pain and was mistakenly given a discontinued antibiotic instead. The facility failed to notify the physician of the missed doses, and the error was not identified until later, highlighting a breakdown in communication and adherence to medication administration policies.
Burn Injury from Improperly Heated Hot Beverage and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision when provided a hot beverage. A resident with diagnoses including a displaced intertrochanteric fracture of the left femur with routine healing, unspecified cataract, unspecified macular degeneration, disorientation, and restlessness and agitation requested very hot tea. The resident had moderate cognitive impairment with a BIMS score of 11 and was care planned as needing set-up assistance with eating and drinking. Although an MDS assessment indicated adequate vision without corrective lenses, subsequent care planning documented vision impairment related to cataracts, macular degeneration, and diplopia, and that the resident wore an eye patch and glasses. On the day of the incident, the resident asked a physical therapy assistant (PTA) to make her tea “very hot.” The PTA dispensed hot water for tea from the kitchenette coffee machine and then heated the beverage in a microwave for an additional 30 seconds at the resident’s request. The PTA then secured a lid on the cup and placed it on the resident’s bedside table. The facility’s Hot Beverage policy, in effect at the time, stated that hot beverages were to be served at a safe, palatable temperature, that hot beverage machines were to be set and maintained at manufacturer-recommended temperatures, and that microwaves were not to be used to reheat hot beverages if the temperature was not considered palatable; instead, a fresh cup was to be poured. The policy also directed staff to report safety or decline in managing hot beverages to the IDT or therapy for review and possible care plan updates. After the PTA placed the lidded cup at the bedside, the visually impaired resident attempted to drink the tea but could not locate the opening in the lid due to her macular degeneration. The resident then attempted to remove the lid independently, during which the hot tea spilled onto her right forearm and right posterior thigh. Nursing assessment documented bright red, blanchable burns with a broken blister on the arm, and measurements of 8 cm by 5 cm on the arm and 12 cm by 22 cm on the thigh. The NP assessed the injuries as second-degree partial thickness burns involving approximately 6% total body surface area, with the resident reporting pain of 3 out of 10 and denying numbness, tingling, fevers, or chills. Subsequent documentation showed the wounds progressing with scabbing and epithelial tissue formation prior to the resident’s discharge home. Staff interviews confirmed that, following the incident, it was recognized that the tea had been heated beyond the temperature at which it was dispensed from the coffee machine and that the resident’s impaired vision contributed to her difficulty using the standard lidded cup. The DON and RN stated that the PTA had reheated the tea in the microwave without checking the temperature and then served it to the resident, contrary to the facility’s policy prohibiting reheating of facility-provided drinks in microwaves. The dietary manager and nursing staff also indicated that the facility’s practice was to avoid reheating hot beverages and to rely on the coffee machine settings, which were kept at or below 160°F, rather than using microwaves for additional heating. These actions and inactions led to the resident being provided an excessively hot beverage in a manner that did not account for her visual impairment, resulting in the burn injury. The facility’s failure centered on not adhering to its own Hot Beverage policy and not adequately supervising or accommodating the resident’s known visual impairment when providing a very hot beverage. The PTA’s use of the microwave to further heat the tea, the absence of a temperature check before serving, and the placement of a standard lid that the visually impaired resident could not safely manage independently all contributed to the incident. The care plan at the time identified the resident as needing set-up assistance and, after the incident, was updated to include interventions such as encouraging the resident to leave lids on hot beverages and to use the call light for assistance with lids, indicating that these precautions were not in place or not implemented at the time of the burn event.
Failure to Provide Timely Assistance With Resident Room-Change Belongings
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences during a room change, specifically by not providing timely assistance with moving the resident’s personal belongings. The facility’s Room Change policy, revised April 2025, states that environmental services staff or a designee will assist residents to pack their belongings prior to a room change, and nursing staff will assist residents to unpack belongings and get settled into the new room. The policy does not specify who will physically move the belongings between rooms, but staff interviews indicated an expectation that environmental services, nursing, or maintenance staff would typically assist with moving items or furniture. The resident involved was under age 65 and had multiple diagnoses, including CVA with left-sided hemiparesis and spastic hemiplegia, coronary artery disease, hyperlipidemia, depression, ADHD, lower back pain, and muscle weakness. The resident was cognitively intact with a BIMS score of 15, used a wheelchair for mobility, and was independent with hygiene, toileting, bathing, and dressing, but required setup and cleanup assistance with eating. The resident had documented verbal behavioral symptoms such as yelling and cursing, and a behavior care plan that included communicating via email and following up on concerns in a timely manner. The resident reported irritation of the nose and eyes and refused to return to her original room after complaining of a strong smell of ammonia and bleach, and staff assisted her into another room that night so she could sleep. Following this move, the resident requested assistance from staff to bring toiletries, a plant, and other personal items from the original room to the new room. Progress notes documented that staff told the resident they were not allowed to move her belongings and could only accompany her while she moved them herself, despite her left-sided hemiplegia and inability to move the items independently. The resident stated she was told she needed to move the items herself or arrange for someone else to move them and that she felt she should not have to pay to move her own items because the facility had offered the room change. Email communications show that the NHA characterized the room change as an accommodation requested by the resident and informed her that, due to prior concerns about staff handling her property, her belongings should be moved by family, an authorized representative, or a third-party mover at her own expense, with staff only providing access and oversight. The resident agreed to permanently move to the new room, but most of her belongings remained in the previous room, and staff continued to only escort her to retrieve items herself. Staff interviews confirmed that, in typical room changes, families or staff would assist with moving belongings, and that in this case the facility did not expect the resident to move her own items but also did not provide direct assistance or documented resources for moving services. The permanent move of the resident’s belongings did not occur until 39 days after she agreed to the room transfer, during which time the majority of her personal items remained in the original room.
Failure to Report Resident’s Verbal Abuse Allegation Involving DON
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the State Agency as required by its own policy and federal regulations. The facility’s Occurrence Reporting–Vulnerable Adult policy, revised in October 2022, requires all alleged violations and substantiated incidents involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property to be reported immediately, but no later than two hours if abuse or serious bodily injury is involved, or within 24 hours if not. Despite this policy, an allegation by a resident that the DON had been verbally abusive was not reported to the State Agency. The resident involved was under age 65 and had multiple diagnoses, including CVA (stroke), hemiparesis, spastic hemiplegia of the left side, coronary artery disease, hyperlipidemia, depression, ADHD, lower back pain, and muscle weakness. A recent MDS assessment documented that the resident was cognitively intact with a BIMS score of 15/15 and exhibited verbal behavioral symptoms such as yelling and cursing. The resident was independent in most ADLs, used a wheelchair for mobility, and had a behavior care plan addressing yelling and inappropriate language, as well as an abuse prevention care plan noting risk for abuse or neglect and the ability to report suspected abuse. On the evening in question, the DON went to the resident’s room to oversee the move of facility-provided furniture to a new room. According to the resident’s interview and emails, the DON stood between the resident and the door with hands on hips, told the resident that staff would move only facility furniture and that the resident must move personal belongings, and argued with the resident when the resident stated she could not move her items due to left-sided paralysis. The resident reported feeling cornered, mocked, and provoked, and stated that the DON repeatedly demanded to know if she would move her belongings, raised her voice, and mocked the resident’s request for written communication and disabilities. The resident emailed the NHA that evening with a recording and written statement, stating she felt mocked and provoked, and the following morning explicitly stated she felt the DON’s behavior was verbally abusive. The NHA received emails from both the resident and the DON describing the argument and reviewed the resident’s audio recording and written statements from the resident and the DON. The NHA also spoke with an RN who had been present and involved corporate personnel in reviewing the materials. After this internal review, the NHA, regional corporate director, and corporate compliance officer concluded that verbal abuse was not substantiated. Based on that conclusion, the NHA did not report the resident’s allegation of abuse to the State Agency. The NHA stated she believed that because she had already investigated and decided the allegation was not substantiated, she did not need to report it, resulting in the facility’s failure to report an allegation of verbal abuse as required by policy and regulation.
Failure to Thoroughly Investigate Resident’s Verbal Abuse Allegation Against DON
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse made by a cognitively intact resident against the DON, as required by the facility’s Occurrence Reporting–Vulnerable Adult policy. That policy directed that all suspected or alleged abuse be promptly and thoroughly investigated, including private interviews with the reporter, the alleged victim, the alleged perpetrator, and potential witnesses, as well as documentation of the investigation results. In this case, the resident, who had a history of CVA with left-sided hemiparesis and spastic hemiplegia, depression, ADHD, and other conditions, reported feeling verbally abused and mocked by the DON during an argument related to moving her belongings to a new room. The resident had a BIMS score of 15, was cognitively intact, and had an abuse prevention care plan indicating she was able to report suspected abuse. On the evening in question, the resident had arranged via email with the NHA for assistance moving to a new room, stating she was not physically able to move her belongings and needed help as an accommodation. The resident reported that no one came to her room at the agreed time, later learning the DON had been waiting in the hallway. When the DON and an RN entered the room, the resident stated that the DON stood between her and the door with hands on her hips, told her staff would move only facility-provided furniture, and insisted the resident move her own personal belongings despite her left-sided paralysis. The resident described feeling cornered and provoked, and reported that the interaction escalated into both parties talking over each other and yelling. She stated that when she requested communication in writing, the DON repeatedly asked if she was going to move her belongings and mocked her request, including questioning whether she could hear, which the resident perceived as demeaning and mocking of her disabilities. The resident emailed the NHA that evening with a recording of the argument and a written statement, stating she felt mocked and provoked by the DON and describing the DON’s behavior as verbally abusive. The DON also emailed the NHA summarizing the encounter, acknowledging that she repeatedly asked the resident if she was going to move that night and that the conversation became louder as they talked over each other. The NHA later stated she listened to the audio recording, reviewed the written statements from both the resident and the DON, and spoke with the RN who was present, but there was no documentation of these investigative steps. The only written follow-up in the record was a brief statement that the RN confirmed he was present and had nothing to add to the DON’s email; there was no documentation of specific questions asked of him, no documented interview of the resident about the incident, no interviews with other residents regarding their interactions with the DON, and no interviews with other staff to determine if anyone overheard the incident. Additionally, despite the resident explicitly stating she felt verbally abused, the allegation was not reported to the State Agency, and the facility could not produce documentation showing that a thorough investigation consistent with its abuse policy and investigation checklist was completed at the time of the allegation. The NHA acknowledged that she did not conduct an in-person interview with the resident, stating that the resident’s written statement served as the interview, and that she did not pursue additional interviews with other staff or residents because, after internal review with corporate personnel, they did not substantiate the event as verbal abuse. The DON, who had experience with other abuse investigations and was aware that terms such as “intimidated” or “provoked” should prompt further inquiry, stated she documented her recollection and later listened to the audio with the NHA, but again, no contemporaneous documentation of these steps was available. Review of the resident’s EMR and email correspondence revealed no additional investigation notes or follow-up communication with the resident regarding her abuse claim. As a result, the facility lacked documentation of a prompt, thorough investigation as required by its own policy, including the absence of detailed interviews, witness statements, and analysis of the audio recording, leading to the cited deficiency for failure to thoroughly investigate an allegation of verbal abuse.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Obtain Physician Orders and Consent for Use of Wanderguard and Secured Unit Placement
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints except as required for medical treatment, as evidenced by the use of a wanderguard and placement in a secured memory care unit without proper physician orders and without obtaining consent from the resident’s representative. The resident, who had diagnoses including Parkinson’s disease, unspecified dementia, Alzheimer’s disease, and anxiety disorder, was cognitively impaired but valued independence and outdoor activities. After an elopement incident, the facility placed a wanderguard on the resident and moved him to the secured unit during the day, but did not have a continuous physician’s order for the device, and the order that was present was only for a single day. The resident continued to wear the wanderguard for an extended period without appropriate orders, and documentation of the device’s use was inconsistent with the resident’s actual status. The facility also failed to obtain consent from the resident’s representative or power of attorney before moving the resident to the secured memory care unit, which restricted his ability to participate in activities that were important to him, such as walking and going outside. Both the resident’s representative and POA expressed concerns that the move was made without their agreement and that the resident was not assessed for the appropriateness of the secured unit. The representative noted that the resident was not provided with personalized activities and that his opportunities for walks and outdoor activities were limited, despite these being identified as very important to him in his care plan and activity assessments. Documentation and staff interviews revealed that the resident’s participation in preferred activities was sporadic and not consistently offered or recorded. Nursing and activity records showed limited engagement in walks and other activities, and there were instances where the resident requested walks but was not accommodated. Staff interviews confirmed that the wanderguard was used as an intervention prior to placement in the secured unit, but the required physician orders and consent processes were not properly followed, leading to the deficiency.
Failure to Address Severe Weight Loss in Residents
Penalty
Summary
The facility failed to ensure adequate nutritional care for two residents, leading to severe weight loss. Resident #10, admitted with dementia, stroke, and seizure disorder, experienced a significant weight loss of 18.6 pounds (12.8%) from July 30, 2024, to August 27, 2024. Despite this severe weight loss, the facility did not implement timely or effective nutritional interventions. Observations revealed that Resident #10 was not offered alternative food options during meals, and the care plan lacked updated interventions to address the weight loss. Resident #35, diagnosed with GERD, arthritis, and a thyroid disorder, also experienced severe weight loss. The resident lost 8 pounds (7%) from August 6, 2024, to September 10, 2024. The facility discontinued the resident's oral nutritional supplement due to perceived weight gain, despite evidence of weight loss. The care plan did not reflect any new interventions to address the resident's nutritional needs after the weight loss was identified. Interviews with staff, including a registered dietitian and the director of nursing, highlighted a lack of awareness and action regarding the residents' weight loss. The dietitian did not expect the nutritional plan to be updated for weight loss and was unaware of interventions for Resident #10. The director of nursing acknowledged discrepancies in documentation and the failure to identify Resident #35 as at risk in the nutrition committee. These oversights contributed to the facility's inability to provide necessary nutritional care for the residents.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to protect a resident from abuse, specifically failing to prevent one resident from slapping another. The incident involved two residents in the memory care unit, both with severe cognitive impairments and dementia. Resident #22 slapped Resident #23 on the hand in the dining room after Resident #23 got too close to her belongings. The facility's investigation determined that the action was not willful harm due to Resident #22's dementia, and no physical injury or psychological harm was noted for Resident #23. The facility's investigation into the incident was incomplete. It did not include interviews with the involved residents to assess their feelings of safety, nor did it involve interviews with other residents or staff members to gather additional insights or concerns about potential abuse. The investigation also lacked documentation of what the residents were doing before the altercation and whether staff attempted to redirect them prior to the incident. The care plans for both residents were reviewed, but no new interventions were put in place for Resident #23 to prevent future altercations. The facility's policy required thorough investigations and the development of interventions to prevent further occurrences, but these steps were not adequately followed. The facility's response to the incident, including behavior monitoring and staff communication, was delayed and insufficient, as noted by the lack of immediate documentation and follow-up actions.
Failure to Conduct Immediate Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following an unwitnessed fall. Specifically, the facility did not take the resident's vital signs immediately after the fall, which is a critical step in post-fall assessment as per professional nursing standards. The resident, who was under 65 years old and had diagnoses including hypertension, renal insufficiency, and COPD, was found sitting on the floor in her bathroom with pain in her coccyx. Despite the fall care plan requiring vital signs to be checked after a fall, the facility did not record the resident's vital signs until two days later. Interviews with staff, including an LPN, the director of rehabilitation, a CNA, and the DON, confirmed that the standard procedure following a fall is to assess the resident immediately, including taking vital signs. The DON emphasized the importance of obtaining vital signs to rule out causes such as low blood pressure or heart rate. However, the fall report for the resident did not include any documentation of vital signs being taken immediately after the fall, indicating a lapse in following the established care plan and professional standards.
Failure to Ensure Stop Dates for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, as required by their policy. Resident #14, who had moderate cognitive impairments and was dependent on staff for daily activities, was prescribed Haloperidol without a stop date, and the medication was used on an as-needed basis for over 14 days without proper documentation from a physician. Similarly, Resident #37, who had severe cognitive impairments and required assistance with daily activities, was also prescribed Haloperidol without a stop date, and the medication was used on an as-needed basis for over 14 days without appropriate documentation. The medical director acknowledged that as-needed psychotropic medications should have a maximum prescribing time of 14 days and admitted that the orders for both residents were incorrect as they lacked stop dates. The director of nursing confirmed that as-needed psychotropic medications cannot be ordered for more than 14 days. The failure to include stop dates for these medications led to the deficiency, as it did not align with the facility's policy and the regulatory requirements for prescribing psychotropic medications.
Significant Medication Error Due to Delayed Delivery and Incorrect Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of antibiotics. The resident, who was over 65 years old and had diagnoses including chronic obstructive pulmonary disease and otitis externa, was supposed to receive cortisporin ear drops for an ear infection. However, the medication was not administered as ordered due to a delay in delivery from an out-of-town pharmacy. The resident did not receive the prescribed antibiotic on the scheduled dates, and there was no documentation indicating that the physician was notified of the missed doses. The resident reported experiencing ear pain over the weekend and had to request pain relief medication. Despite the physician's order for cortisporin ear drops, the medication was not available until several days later. During this period, the resident was mistakenly given a discontinued antibiotic, neomycin-polymyxin ear drops, instead of the prescribed cortisporin. This error occurred because the discontinued medication was not removed from the medication cart, leading to the administration of the wrong antibiotic. Interviews with staff revealed a lack of communication and documentation regarding the delay in medication delivery and the administration of the incorrect antibiotic. The Director of Nursing (DON) was not informed of the medication delay or the administration error until after the fact. The facility's policies on medication administration and physician notification were not followed, contributing to the significant medication error experienced by the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eagle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Park Care Center | 26.2 mi | — | 0 | 0 |
| Glenwood Springs Healthcare | 27.2 mi | — | 3 | 0 |
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