Deficiency Records for Cape Heritage Rehabilitation and Health Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Cape Heritage Rehabilitation and Health Care 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-05 | 2022-12-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-05 | 2022-12-30 | 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 | 2022-10-05 | 2022-12-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-05 | 2022-12-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-05 | 2022-12-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-05 | 2022-12-30 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-10-05 | 2022-12-30 | 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 | 2022-10-05 | 2022-12-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-05 | 2022-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-05 | 2022-12-30 | 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 | 2022-10-05 | 2022-12-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-05 | 2022-11-19 | 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 | 2022-10-05 | 2022-11-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-10-05 | 2022-11-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-05 | 2022-11-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-05 | 2022-11-19 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-05 | 2022-11-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-05 | 2022-11-19 | 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 | 2022-10-05 | 2022-11-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-05 | 2022-11-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-05 | 2022-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-05 | 2022-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2022-11-19 | 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 | 2022-10-05 | 2022-11-19 | 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 | 2022-10-05 | 2022-11-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-05 | 2022-11-19 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-05 | 2022-11-19 | 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 | 2022-10-05 | 2022-11-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-05 | 2022-11-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-05 | 2022-11-19 | 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 | 2022-10-05 | 2022-11-19 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-10-05 | 2022-11-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-05 | 2022-11-19 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-10-05 | 2022-11-19 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-05 | 2022-11-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-05 | 2022-11-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-05 | 2022-11-19 | N |
| Report COVID19 data to residents and families. | Health | 2022-10-05 | 2022-11-19 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-05 | 2022-11-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-05 | 2022-11-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-04 | 2022-11-18 | 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 | 2022-10-04 | 2022-11-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-05-24 | 2022-07-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-24 | 2022-07-15 | 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 | 2022-05-24 | 2022-07-15 | 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 | 2022-05-24 | 2022-07-15 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-05-24 | 2022-07-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-04 | 2022-05-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-20 | 2022-02-03 | Y |
| 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 | 2021-08-13 | 2021-09-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-13 | 2021-09-26 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-08-13 | 2021-09-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-13 | 2021-09-26 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-26 | 2020-03-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-26 | 2020-03-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-26 | 2020-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-26 | 2020-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-26 | 2020-03-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-10 | 2020-01-22 | 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 | 2020-01-10 | 2020-01-22 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-01-10 | 2020-01-22 | 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 | 2020-01-10 | 2020-01-22 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-01-10 | 2020-01-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-11-28 | 2019-01-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-28 | 2019-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-28 | 2019-01-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-28 | 2019-01-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-11-28 | 2019-01-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-30 | 2018-12-12 | 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 | 2018-10-30 | 2018-12-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-10-30 | 2018-12-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-10-30 | 2018-12-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-30 | 2018-12-12 | N |
