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 Pines Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was mistakenly given another resident's Glatiramer Acetate injection by an LVN who confused two residents with similar names. The error was discovered after a family member questioned the medication, and the resident was monitored and transferred to the hospital for observation. Facility policy requiring proper resident identification prior to medication administration was not followed, resulting in the medication error.
The facility failed to follow the menu for two meals, resulting in residents not receiving margarine as listed on their tray cards. This deficiency was observed for two cognitively intact residents who required set-up service only for meals. Staff interviews and observations confirmed that the kitchen staff did not consistently add margarine to the trays, despite it being part of the diet orders.
The facility failed to develop a comprehensive care plan for a resident with a tracheostomy who refused staff assistance and performed her own care. Despite multiple educational attempts by the nursing staff, the care plan did not address the resident's refusals or her desire to perform her own care, nor was there an assessment to determine if she could safely do so.
The facility failed to provide safe and appropriate respiratory care for two residents. One resident with a tracheostomy performed her own care without proper hygiene, and another resident's nebulizer mask was not dated or stored correctly. These deficiencies put residents at risk of infections and other complications.
A medication aide failed to perform hand hygiene during medication administration for two residents, potentially exposing them to infections. The aide did not sanitize or wash hands before or after handling medications, despite facility policies emphasizing the importance of hand hygiene.
Resident Administered Another Resident's Medication Due to Identification Error
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including dementia and hypertension, was administered a medication not prescribed to him. The medication, Glatiramer Acetate, used to treat multiple sclerosis, was given by an LVN who had recently returned to work and confused two residents with similar names who were located next to each other. The resident's care plan and physician's orders did not include this medication, and the error was discovered after a family member questioned the administration of a multiple sclerosis medication. Upon investigation, it was confirmed that the resident had received the wrong medication during the morning medication pass. The LVN reported that the resident appeared to expect the injection, which contributed to the error. The incident was documented in the nursing progress notes, and the resident was monitored for adverse reactions, with none observed at the time. The resident's vital signs and physical assessment were within normal limits following the administration of the incorrect medication. The error was identified after the family member raised concerns, prompting a review of the resident's diagnoses and medication orders. The resident was subsequently transferred to the hospital for further monitoring at the request of the family. The facility's policy required correct resident identification prior to medication administration, which was not followed in this instance, leading to the medication error.
Failure to Follow Menu for Resident Meals
Penalty
Summary
The facility failed to ensure that the menu was followed for two meals, specifically the lunch meal on 03/25/24 and the breakfast meal on 03/26/24. During these meals, residents did not receive margarine as listed on their tray cards. This deficiency was observed for Resident #8 and Resident #150, both of whom were cognitively intact and required set-up service only for meals. Resident #8, who was admitted for therapy after leg surgery, and Resident #150, who had diagnoses including protein calorie malnutrition and pneumonia, both reported not receiving margarine as indicated on their meal trays. Observations confirmed that margarine was missing from the trays of multiple residents on both days, despite being listed on the tray cards. Interviews with staff and residents revealed that the kitchen staff was responsible for checking the trays for accuracy and adding condiments, but this was not consistently done. The Dietary Director acknowledged that margarine should be added to the trays as part of the diet orders and that its absence could affect meal enjoyment. The Administrator confirmed that a performance improvement plan had been initiated to address the issue, but the deficiency was noted during the survey period. The facility's policy on resident meal service emphasized honoring resident food preferences, but this was not adhered to in the observed instances.
Failure to Develop Comprehensive Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a tracheostomy. The resident, who had a moderate cognitive impairment and a history of acute respiratory failure with hypoxia, was observed performing her own tracheostomy care without wearing gloves. Despite multiple educational attempts by the nursing staff, the resident continued to refuse assistance and insisted on performing the care herself. The care plan did not address the resident's refusals or her desire to perform her own tracheostomy care, nor was there an assessment to determine if she could safely perform the care on her own. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the resident was very particular about her tracheostomy care and consistently refused staff assistance. The staff had educated the resident on the risks of performing her own care, but she remained adamant that she knew what she was doing. The DON acknowledged that the resident's physician was aware of the situation and that the resident could be at increased risk of infections by performing her own tracheostomy care. The facility's policy on comprehensive care planning stated that the care plan should identify any care or service being declined by the resident, the risks posed by the declination, and the efforts by the interdisciplinary team to educate the resident. However, the care plan for this resident did not include these elements, leading to a deficiency in providing appropriate interventions to meet the resident's needs. The MDS coordinators admitted that the care planning process might have been missed, and they discussed potential improvements to ensure timely and comprehensive care plans in the future.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences. Resident #41, who had a tracheostomy and a moderate cognitive impairment, was observed performing her own tracheostomy care without wearing gloves or using hand sanitizer. Despite multiple educations from the nursing staff about the risks, Resident #41 insisted on performing her own care. The facility did not have a safe assessment for her to perform her own tracheostomy care, and her comprehensive care plan did not address her refusal to allow staff to perform the care or her practice of performing it herself. Additionally, Resident #41 had a history of infection at the tracheostomy site, which was not adequately addressed in her care plan or physician orders. Resident #81, who had dementia and required nebulizer treatments for shortness of breath, was found to have a nebulizer mask that was not dated or stored properly between uses. The mask was observed laying on her bedside table without a plastic bag for storage. The nursing staff and DON acknowledged that the nebulizer mask should be dated, changed weekly, and stored in a plastic bag to prevent infections. However, there was no physician order for changing the nebulizer mask weekly, and the staff failed to follow the facility's policy for nebulizer care. These deficiencies indicate that the facility did not provide safe and appropriate respiratory care for residents requiring such care. The lack of proper assessments, documentation, and adherence to facility policies put residents at risk of infections and other complications related to their respiratory conditions.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of a medication aide (MA H) during medication administration for two residents. MA H did not perform hand hygiene before or after administering medications to Resident #23 and Resident #24. Specifically, MA H did not sanitize or wash her hands before taking Resident #23's blood pressure, handling medications, or after administering them. Similarly, for Resident #24, MA H did not wash or sanitize her hands before unlocking the medication cart, handling medications, or after administering them, even after re-entering the room to provide a missed dose of medication. Resident #23, who has a diagnosis of dementia, Type 2 diabetes, systolic heart failure, and BPH, was observed during a medication pass where MA H failed to perform hand hygiene. Resident #23's care plan included interventions to administer medications as ordered, and his physician order summary allowed for medications to be crushed or capsules to be opened as needed. Despite these precautions, MA H did not follow proper hand hygiene protocols, potentially exposing Resident #23 to communicable diseases and infections. Resident #24, diagnosed with Type 2 diabetes, lymphedema, and major depressive disorder, also experienced a lapse in infection control during medication administration. MA H did not sanitize her hands before handling Resident #24's medications and failed to do so even after re-entering the room to administer a missed dose of furosemide. Interviews with MA H, the ADON, the DON, and the Administrator confirmed that proper hand hygiene protocols were not followed, which could place residents at risk for infections. The facility's policy on infection control emphasizes the importance of hand hygiene as the primary means of preventing the transmission of infections.
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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 Lufkin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kennedy Health & Rehab | 0.3 mi | — | 14 | 7 |
| Larkspur | 0.8 mi | — | 3 | 0 |
| Parkwood In The Pines | 1.1 mi | — | 11 | 0 |
| Pinecrest Retirement Community | 2.2 mi | — | 2 | 0 |
| Southland Rehabilitation And Healthcare Center | 4.3 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.