Deficiency Records for Capitol City Rehab and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Capitol City Rehab and Healthcare 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-24 | 2023-06-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-24 | 2023-06-15 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-24 | 2023-06-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-02 | 2023-03-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-05 | 2022-07-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-23 | 2022-03-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-23 | 2022-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-23 | 2022-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-23 | 2022-02-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-23 | 2022-02-23 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-12-23 | 2022-02-23 | 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 | 2021-12-23 | 2022-02-23 | 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 | 2021-12-23 | 2022-02-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-23 | 2022-02-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-23 | 2022-02-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-23 | 2022-02-23 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-23 | 2022-02-23 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-12-23 | 2022-02-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-23 | 2022-02-23 | 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 | 2021-12-23 | 2022-02-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-23 | 2022-02-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-12-23 | 2022-02-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-23 | 2022-02-23 | 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 | 2021-12-23 | 2022-02-23 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-12-23 | 2022-02-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-23 | 2022-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-23 | 2022-02-23 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-12-23 | 2022-02-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-23 | 2022-02-23 | 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 | 2021-12-23 | 2022-02-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-23 | 2022-02-23 | N |
| 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 | 2021-12-23 | 2022-02-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-23 | 2022-02-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-23 | 2022-02-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-23 | 2022-02-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-23 | 2022-02-23 | 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 | 2021-12-23 | 2022-02-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-23 | 2022-02-23 | 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 | 2021-12-23 | 2022-02-23 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-12-23 | 2022-02-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-23 | 2022-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-23 | 2022-02-23 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-12-23 | 2022-02-23 | 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 | 2021-12-23 | 2022-02-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-23 | 2022-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-23 | 2022-02-23 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-23 | 2022-02-23 | 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 | 2021-12-23 | 2022-02-23 | N |
| Keep all essential equipment working safely. | Health | 2021-12-23 | 2022-02-23 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-12-23 | 2022-02-23 | N |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2022-01-27 | 2022-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-23 | 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 | 2022-01-27 | 2022-02-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-12-23 | 2022-02-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-12-23 | 2022-02-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-12-23 | 2022-02-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-12-23 | 2022-02-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-12-23 | 2022-02-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-12-23 | 2022-02-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-20 | 2020-04-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-20 | 2020-04-08 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2020-02-20 | 2020-04-08 | 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 | 2020-02-20 | 2020-04-08 | 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 | 2020-02-20 | 2020-04-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-20 | 2020-04-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-20 | 2020-04-08 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-20 | 2020-04-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-20 | 2020-04-08 | 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 | 2020-02-20 | 2020-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-20 | 2020-04-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-20 | 2020-04-08 | N |
| 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 | 2020-02-20 | 2020-04-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-20 | 2020-04-08 | 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 | 2020-02-20 | 2020-04-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-20 | 2020-04-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-20 | 2020-04-08 | 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 | 2020-02-20 | 2020-04-08 | N |
| Post nurse staffing information every day. | Health | 2020-02-20 | 2020-04-08 | 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 | 2020-02-20 | 2020-04-08 | 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 | 2020-02-20 | 2020-04-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-20 | 2020-04-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-20 | 2020-04-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-20 | 2020-04-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-20 | 2020-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-20 | 2020-04-08 | N |
| Keep all essential equipment working safely. | Health | 2020-02-20 | 2020-04-08 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-02-20 | 2020-04-08 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-02-20 | 2020-04-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-02-20 | 2020-04-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-20 | 2020-04-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-20 | 2020-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-20 | 2020-04-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-20 | 2020-04-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-20 | 2020-04-08 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-02-20 | 2020-04-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-12-14 | 2019-02-14 | 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 | 2018-12-14 | 2019-02-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-12-14 | 2019-02-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-12-14 | 2019-02-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-12-14 | 2019-02-14 | N |
| Respond appropriately to all alleged violations. | Health | 2018-12-14 | 2019-02-14 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-12-14 | 2019-02-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-12-14 | 2019-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-14 | 2019-02-14 | 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 | 2018-12-14 | 2019-02-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-12-14 | 2019-02-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-14 | 2019-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-14 | 2019-02-14 | 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 | 2018-12-14 | 2019-02-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-12-14 | 2019-02-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-12-14 | 2019-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-14 | 2019-02-14 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-12-14 | 2019-02-14 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2018-12-14 | 2019-02-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-14 | 2019-02-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-12-14 | 2019-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-14 | 2019-02-14 | N |
| Keep all essential equipment working safely. | Health | 2018-12-14 | 2019-02-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-12-14 | 2019-02-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-14 | 2019-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-14 | 2019-02-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-14 | 2019-02-14 | N |
