Resident #1 had been exhibiting challenging behaviors over several weeks, including attempting to have sex with another dementia resident who could not consent, escaping from the facility, and striking a certified nurse aide. The facility's doctor determined he needed inpatient geriatric psychiatric treatment and deemed it unsafe to have him near other vulnerable residents.
But after the hospital stabilized the patient, Castle Peak refused to take him back.
"The facility left Resident #1 in the hospital's care and did not help the resident find a different facility to be discharged to," the hospital case manager told state inspectors during an August investigation. She said no one from Castle Peak reassessed the patient when he was medically cleared. "There was no reason for the hospital to keep the resident."
The case manager said she felt the resident was "dumped at the hospital."
The patient's representative echoed that assessment. "The facility refused to readmit the resident once he was medically cleared," the representative told inspectors. "The facility did not help the resident find an alternate facility. The representative felt the resident was abandoned by the facility."
Most telling: the patient displayed no behavioral problems during his hospital stay. "The resident had no behaviors at the hospital," his representative said. The hospital case manager confirmed that "Resident #1 displayed no behaviors of any type while he was in the hospital, so she was confused as to why the facility refused to readmit the resident."
Castle Peak's Director of Nursing revealed a troubling lack of understanding about basic discharge requirements. When asked about reassessing the patient, she told inspectors "she was not aware someone needed to reassess the resident when he was medically cleared prior to discharging him."
She also misunderstood where patients could be discharged. "The DON said the receiving facility for Resident #1 was the hospital. She said she was not aware that the hospital was not an acceptable discharge location."
The patient's behavioral issues had been significant. During his stay at Castle Peak, he had escaped twice - once hitchhiking a mile away trying to reach his ex-wife in another state, another time found half a mile from the facility. Staff also discovered him naked in a female resident's room with a woman unable to consent to sexual contact.
The facility had initially tried interventions including a one-to-one sitter and starting him on Depakote, an anti-seizure medication used to manage behaviors. When those measures proved insufficient, the facility's physician recommended psychiatric hospitalization.
But federal regulations require nursing homes to properly plan discharges, including reassessing residents after stabilization and ensuring appropriate placement. Castle Peak failed on multiple fronts.
State inspectors found no documentation that the facility reassessed the resident after his hospital stabilization. They found no evidence Castle Peak documented what services the receiving facility would provide that they couldn't. Most critically, inspectors could find no discharge summary in the patient's electronic medical record.
The Director of Nursing's interview revealed the facility's pattern of problems with this resident had begun almost immediately. She said the family initially told them he could walk outside independently, but the facility discovered he had fallen during an unsupervised walk only when he complained of shoulder pain the next day.
"She found out the resident fell outside by himself a day later when he complained of shoulder pain and explained he fell the day before," according to the inspection report.
The case highlights how vulnerable dementia patients can become caught between facilities unwilling to manage challenging behaviors and hospitals that aren't designed for long-term psychiatric care. Federal inspectors cited Castle Peak for failing to ensure orderly transfers and discharges, noting the violation caused minimal harm but affected few residents.
The patient's representative and the hospital case manager both used the same word to describe what happened: abandonment. Castle Peak had taken responsibility for caring for a vulnerable dementia patient, then walked away when his condition became difficult to manage, leaving him stranded in an inappropriate setting without proper discharge planning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Castle Peak Senior Life and Rehabilitation from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
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