A list of the most recent deficiencies for Capitol Lakes Health 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? |
|---|---|---|---|---|
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-10-05 | 2023-12-19 | 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 | 2023-10-05 | 2023-11-03 | 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 | 2023-10-05 | 2023-11-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-05 | 2023-11-03 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-10-05 | 2023-11-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-10-05 | 2023-10-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-05 | 2023-10-23 | 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 | 2023-10-05 | 2023-10-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-10-05 | 2023-10-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-05 | 2023-10-23 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-05 | 2023-10-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-05 | 2023-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-05 | 2023-10-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-21 | 2023-07-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-21 | 2023-07-18 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-08-11 | 2022-09-09 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-11 | 2022-09-09 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-08-11 | 2022-09-09 | N |
| 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 | 2022-08-11 | 2022-09-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-11 | 2022-09-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-11 | 2022-09-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-11 | 2022-09-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-09 | 2022-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-09-08 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-08-09 | 2022-09-02 | N |
| 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 | 2022-08-09 | 2022-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-08-09 | 2022-08-12 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-08-09 | 2022-08-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-09 | 2022-08-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-09 | 2022-08-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-26 | 2021-07-22 | N |
| 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 | 2021-05-26 | 2021-07-22 | 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 | 2021-05-26 | 2021-07-22 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-05-26 | 2021-07-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-26 | 2021-07-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-26 | 2021-07-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-26 | 2021-07-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-26 | 2021-07-22 | 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 | 2021-05-26 | 2021-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-26 | 2021-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-26 | 2021-06-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-26 | 2021-06-25 | N |
