Deficiency Records for North Capitol Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for North Capitol Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-15 | 2023-09-01 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-21 | 2023-04-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-21 | 2023-04-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-21 | 2023-04-07 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-07 | 2023-04-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-07 | 2023-04-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-07 | 2023-04-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-07 | 2023-04-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-07 | 2023-04-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-07 | 2023-04-07 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-07 | 2023-04-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-07 | 2023-04-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-07 | 2023-04-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-03 | 2023-01-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-07 | 2022-10-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-07 | 2022-10-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-07 | 2022-10-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-11 | 2022-06-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-11 | 2022-06-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-11 | 2022-06-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-11 | 2022-06-02 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-11 | 2022-06-02 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-02-08 | 2022-02-25 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-10-06 | 2021-11-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-06 | 2021-11-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-21 | 2021-10-25 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-09-21 | 2021-10-25 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-08-18 | 2020-11-09 | 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 | 2020-08-18 | 2020-11-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-08-18 | 2020-11-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-08-18 | 2020-10-06 | N |
| Use approved construction type or materials. | Fire Safety | 2020-08-18 | 2020-09-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-11 | 2020-03-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-02-11 | 2020-03-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-02-11 | 2020-03-12 | 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 | 2020-02-11 | 2020-03-12 | 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 | 2020-02-11 | 2020-03-12 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2020-02-11 | 2020-03-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-11 | 2020-03-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-02-11 | 2020-03-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-11 | 2020-03-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-02-11 | 2020-03-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-11 | 2020-03-12 | 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 | 2020-02-11 | 2020-03-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-11 | 2020-03-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-11 | 2020-03-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-11 | 2020-03-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-11 | 2020-03-12 | 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 | 2020-02-11 | 2020-03-12 | 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 | 2020-02-11 | 2020-03-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-11 | 2020-03-12 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2020-02-11 | 2020-03-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-11 | 2020-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-11 | 2020-03-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-11 | 2020-03-12 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-13 | 2019-04-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-02-12 | 2019-03-14 | 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 | 2019-02-12 | 2019-03-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-12 | 2019-03-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-12 | 2019-03-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-12 | 2019-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-12 | 2019-03-14 | N |
