A list of the most recent deficiencies for Cadia Rehabilitation Capitol. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-08 | 2023-12-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-08 | 2023-12-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-08 | 2023-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-08 | 2023-12-08 | 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 | 2023-11-08 | 2023-12-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-08 | 2023-12-08 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-08 | 2023-12-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-08 | 2023-12-08 | N |
| 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 | 2023-11-08 | 2023-12-08 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-11-08 | 2023-12-08 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-08 | 2023-12-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-11-08 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-08 | 2023-12-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-08 | 2023-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-08 | 2023-12-08 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-08 | 2023-12-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-03-29 | 2022-05-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-29 | 2022-05-16 | 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 | 2022-03-29 | 2022-05-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-29 | 2022-05-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-29 | 2022-05-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-29 | 2022-05-16 | 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 | 2022-03-29 | 2022-05-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-29 | 2022-05-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-29 | 2022-05-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-29 | 2022-05-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-29 | 2022-05-16 | Y |
| 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 | 2022-03-31 | 2022-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-31 | 2022-04-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-31 | 2022-04-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-18 | 2019-08-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-06-18 | 2019-08-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-18 | 2019-08-02 | 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 | 2019-06-18 | 2019-08-02 | 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 | 2019-06-18 | 2019-08-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-18 | 2019-08-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-18 | 2019-08-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-18 | 2019-08-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-18 | 2019-08-02 | N |
| 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 | 2019-06-18 | 2019-08-02 | 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 | 2019-06-18 | 2019-08-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-18 | 2019-08-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-06-18 | 2019-08-02 | 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 | 2019-06-18 | 2019-02-28 | N |
