Castle Peak Senior Life And Rehabilitation

unpredictable behaviors over the past few weeks.

The behaviors included attempting to have sex with another dementia resident who was unable to consent, eloping from the facility and physically striking a certified nurse aide (CNA). Resident #1 was previously evaluated and interventions such as a one-to-one sitter and starting Depakote (anti-seizure medication used for behaviors) were implemented.

The MD documented in her medical opinion, Resident #1 required inpatient geriatric psychiatric treatment until his behaviors stabilized.

The MD documented it was unsafe to have Resident #1 in proximity of the other vulnerable residents at the facility and Resident #1 was involuntarily discharged .-There was no documentation to indicate the facility reassessed the resident after he was stabilized at the hospital.-The facility failed to document the needs the receiving facility was going to provide for the resident that the current facility was unable to provide.-Review of Resident #1's electronic medical record (EMR) did not reveal the facility completed a discharge summary for Resident #1.III. Resident #1's representative interviewThe resident's representative was interviewed on 8/20/25 at 2:10 p.m.

The representative said the resident was admitted to the hospital because the facility refused to readmit the resident once he was medically cleared.

The representative said the facility did not help the resident find an alternate facility.

The representative felt the resident was abandoned by the facility.

The representative said the resident had no behaviors at the hospital.IV.

InterviewsThe case manager from the hospital was interviewed on 8/20/25 at 2:00 p.m.

The case manager said the facility left Resident #1 in the hospital's care and did not help the resident find a different facility to be discharged to.

She said no one from the facility reassessed Resident #1 when he was medically cleared and there was no reason for the hospital to keep the resident.

She said she felt the resident was dumped at the hospital.

She said 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.The DON was interviewed on 8/20/25 at 2:30 p.m.

The DON said when Resident #1 was first admitted to the facility, the family said he was able to go on walks outside the facility by himself.

She said during the resident's admission, 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.

The DON said the resident was located a mile away from the facility and was hitchhiking to another state to see his ex-wife.

She said there was a second incident where the resident was found a half mile away from the facility and he told the staff he wanted to go to another state.

She said the resident was found naked in a female resident's room and she was unable to consent.

The DON said the resident also struck a CNA in the face.

She said no one from the facility reassessed the resident and she was not aware someone needed to reassess the resident when he was medically cleared prior to discharging him.

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.

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