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Deficiency Records for Capitol Lakes Health Center

A list of the most recent deficiencies for Capitol Lakes Health 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 Capitol Lakes Health 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?
Meet requirements for sections of health care facilities separated by fire resistive construction. Fire Safety 2023-10-05 2023-12-19 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2023-10-05 2023-11-03 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 2023-10-05 2023-11-03 N
Ensure medication error rates are not 5 percent or greater. Health 2023-10-05 2023-11-03 N
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2023-10-05 2023-11-03 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2023-10-05 2023-10-26 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-10-05 2023-10-23 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 2023-10-05 2023-10-23 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2023-10-05 2023-10-23 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-10-05 2023-10-23 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2023-10-05 2023-10-18 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-10-05 2023-10-18 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-10-05 2023-10-16 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-06-21 2023-07-18 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-06-21 2023-07-18 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2022-08-11 2022-09-09 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2022-08-11 2022-09-09 N
Keep residents' personal and medical records private and confidential. Health 2022-08-11 2022-09-09 N
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2022-08-11 2022-09-09 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-08-11 2022-09-09 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-08-11 2022-09-09 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-08-11 2022-09-09 N
Have proper medical gas storage and administration areas. Fire Safety 2022-08-09 2022-09-09 N
Provide and implement an infection prevention and control program. Health 2022-08-11 2022-09-08 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2022-08-09 2022-09-02 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2022-08-09 2022-08-30 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-08-09 2022-08-26 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2022-08-09 2022-08-12 N
Meet requirements for sections of health care facilities separated by fire resistive construction. Fire Safety 2022-08-09 2022-08-11 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-08-09 2022-08-11 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-08-09 2022-08-11 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2021-05-26 2021-07-22 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2021-05-26 2021-07-22 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 2021-05-26 2021-07-22 N
Construct fire resistant interior walls. Fire Safety 2021-05-26 2021-07-22 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-05-26 2021-07-22 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2021-05-26 2021-07-22 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-05-26 2021-07-22 N
Have proper medical gas storage and administration areas. Fire Safety 2021-05-26 2021-07-22 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 2021-05-26 2021-06-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-05-26 2021-06-25 N
Provide and implement an infection prevention and control program. Health 2021-05-26 2021-06-25 N
Implement a program that monitors antibiotic use. Health 2021-05-26 2021-06-25 N

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