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Deficiency Records for Cape Regency Rehabilitation and Health Care Center
A list of the most recent deficiencies for Cape Regency Rehabilitation and 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 Cape Regency Rehabilitation and 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2024-04-17 | 2024-05-20 | 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 | 2024-04-17 | 2024-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-17 | 2024-05-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-04-17 | 2024-05-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-17 | 2024-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-17 | 2024-05-20 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-04-01 | 2024-04-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-04-01 | 2024-04-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-04-01 | 2024-04-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-01 | 2024-04-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-01 | 2024-04-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-01 | 2024-04-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-04-01 | 2024-04-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-04-01 | 2024-04-29 | 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 | 2024-04-01 | 2024-04-29 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-04-01 | 2024-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-01 | 2024-04-29 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-04-01 | 2024-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-01 | 2024-04-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-04-01 | 2024-04-29 | N |
| Keep all essential equipment working safely. | Health | 2024-04-01 | 2024-04-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-09 | 2023-06-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-09 | 2023-06-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-22 | 2022-11-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-09-20 | 2022-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-22 | 2022-10-14 | 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 | 2022-09-22 | 2022-10-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-22 | 2022-10-14 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-22 | 2022-10-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-22 | 2022-10-14 | 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 | 2022-09-22 | 2022-10-14 | 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 | 2022-09-22 | 2022-10-14 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-09-22 | 2022-10-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-22 | 2022-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-22 | 2022-10-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-22 | 2022-10-14 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-22 | 2022-10-14 | N |
| Keep all essential equipment working safely. | Health | 2022-09-22 | 2022-10-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-30 | 2019-12-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-30 | 2019-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-30 | 2019-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-30 | 2019-12-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-30 | 2019-12-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-12 | 2019-11-05 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-09-12 | 2019-11-05 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-09-12 | 2019-11-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-12 | 2019-11-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-12 | 2019-11-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-12 | 2019-11-05 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-09-12 | 2019-11-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-12 | 2019-11-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-12 | 2019-11-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-12 | 2019-11-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-12 | 2019-11-05 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-12 | 2019-11-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-12 | 2019-11-05 | 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 | 2019-09-12 | 2019-11-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-09-12 | 2019-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-11-05 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-09-12 | 2019-11-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-12 | 2019-11-05 | N |
| Keep all essential equipment working safely. | Health | 2019-09-12 | 2019-11-05 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-09-12 | 2019-11-05 | N |
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