Deficiency Records for Capital City Gardens Rehabilitation and Nursing Ce
Updated as of March 01, 2024
A list of the most recent deficiencies for Capital City Gardens Rehabilitation and Nursing Ce. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-07 | 2023-11-13 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-11-07 | 2023-11-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-07 | 2023-11-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-07 | 2023-11-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-14 | 2023-08-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-24 | 2023-04-28 | 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 | 2023-03-16 | 2023-04-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-06 | 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 | 2023-03-14 | 2023-04-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-14 | 2023-04-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-14 | 2023-04-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-14 | 2023-04-06 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-03-14 | 2023-04-06 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-03-14 | 2023-04-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-11 | 2022-10-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-29 | 2022-10-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-09 | 2022-10-12 | Y |
| 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 | 2022-08-29 | 2022-10-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-29 | 2022-10-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-29 | 2022-10-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-29 | 2022-10-11 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-08-29 | 2022-10-11 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-29 | 2022-10-11 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-29 | 2022-10-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-29 | 2022-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-29 | 2022-10-11 | Y |
| 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 | 2022-07-27 | 2022-10-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-27 | 2022-10-11 | 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 | 2022-07-27 | 2022-10-11 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-07-27 | 2022-10-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-22 | 2022-10-11 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-22 | 2022-10-11 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-22 | 2022-10-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-22 | 2022-10-11 | 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 | 2022-06-22 | 2022-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-22 | 2022-10-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-09 | 2022-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-09 | 2022-10-11 | Y |
| 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 | 2022-06-09 | 2022-10-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-09 | 2022-10-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-29 | 2022-09-13 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-07-27 | 2022-07-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-28 | 2022-04-18 | Y |
| 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 | 2022-03-07 | 2022-04-18 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-02-02 | 2022-02-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-02-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-05 | 2022-02-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-05 | 2022-02-18 | Y |
| 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 | 2021-11-17 | 2021-11-18 | Y |
| 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 | 2021-09-02 | 2021-11-18 | 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 | 2021-09-02 | 2021-10-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-02 | 2021-10-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-02 | 2021-10-21 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-08-10 | 2021-10-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-10 | 2021-10-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-10 | 2021-10-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-10 | 2021-10-21 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-03-28 | 2021-08-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-09 | 2019-11-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-09 | 2019-11-04 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-09 | 2019-11-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-09 | 2019-11-04 | 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 | 2019-10-09 | 2019-11-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-09 | 2019-11-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-09 | 2019-11-04 | 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 | 2019-10-09 | 2019-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-09 | 2019-11-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-09 | 2019-11-04 | 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 | 2019-10-09 | 2019-11-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-09 | 2019-11-04 | 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 | 2019-10-09 | 2019-11-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-09 | 2019-11-04 | 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 | 2019-10-09 | 2019-11-04 | 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 | 2019-10-09 | 2019-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-09 | 2019-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-09 | 2019-11-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-07 | 2019-11-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-07 | 2019-11-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-07 | 2019-11-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-07 | 2019-11-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-07 | 2019-10-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-10-25 | 2018-11-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-25 | 2018-11-21 | N |
| Respond appropriately to all alleged violations. | Health | 2018-10-25 | 2018-11-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-25 | 2018-11-21 | 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 | 2018-10-25 | 2018-11-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-25 | 2018-11-21 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-10-25 | 2018-11-21 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2018-10-25 | 2018-11-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-25 | 2018-11-21 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-25 | 2018-11-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-25 | 2018-11-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-25 | 2018-11-21 | 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 | 2018-10-25 | 2018-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-25 | 2018-11-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-10-25 | 2018-11-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-25 | 2018-11-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-10-25 | 2018-11-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-22 | 2018-11-21 | N |
| 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 | 2018-10-22 | 2018-11-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-10-22 | 2018-11-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-10-22 | 2018-11-21 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2018-10-22 | 2018-11-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-22 | 2018-11-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-22 | 2018-11-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-22 | 2018-11-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-22 | 2018-11-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-22 | 2018-11-21 | N |
