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Deficiency Records for Capital Post Acute
A list of the most recent deficiencies for Capital Post Acute. 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 Capital Post Acute. 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? |
|---|---|---|---|---|
| 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 | 2024-08-06 | 2024-08-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-04 | 2024-05-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-12 | 2024-04-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-19 | 2024-04-17 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-03-22 | 2024-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-26 | 2024-03-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-22 | 2024-03-11 | Y |
| 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 | 2024-02-16 | 2024-03-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-01 | 2024-02-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-06 | 2024-02-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-29 | 2024-02-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-18 | 2024-02-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-18 | 2024-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-18 | 2024-02-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-02 | 2024-01-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-06 | 2023-12-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-30 | 2023-12-10 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-10-16 | 2023-10-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-16 | 2023-10-23 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-14 | 2023-10-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-14 | 2023-10-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-14 | 2023-10-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-14 | 2023-10-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-14 | 2023-10-09 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-09-14 | 2023-10-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-10-09 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-14 | 2023-10-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-09 | Y |
| 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 | 2023-09-14 | 2023-10-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-08 | 2023-09-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-08 | 2023-09-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-08 | 2023-09-22 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-09-18 | 2023-09-22 | 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 | 2023-09-18 | 2023-09-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-18 | 2023-09-22 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-07-17 | 2023-07-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-12 | 2023-06-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-09 | 2023-06-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-09 | 2023-02-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-18 | 2022-11-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-18 | 2022-11-14 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-10-12 | 2022-11-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-05 | 2022-10-31 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-02 | 2022-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-08 | 2022-09-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-22 | 2022-09-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-29 | 2022-07-21 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-23 | 2022-07-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-17 | 2022-07-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-26 | 2022-07-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-18 | 2022-07-21 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-06 | 2022-07-20 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-29 | 2022-04-14 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-15 | 2022-01-15 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-17 | 2021-07-19 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-06-17 | 2021-07-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-17 | 2021-07-19 | 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 | 2021-06-10 | 2021-06-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-10 | 2021-06-28 | 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 | 2021-06-10 | 2021-06-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-10 | 2021-06-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-10 | 2021-06-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-06 | 2019-11-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-06 | 2019-11-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-06 | 2019-11-25 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-11-06 | 2019-11-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-06 | 2019-11-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-06 | 2019-11-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-06 | 2019-11-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-10 | 2019-11-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-10 | 2019-11-07 | 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 | 2019-10-10 | 2019-11-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-10 | 2019-11-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-10 | 2019-11-07 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-10-10 | 2019-11-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-10 | 2019-11-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-11-07 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-10-10 | 2019-11-07 | N |
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