Capitol Lakes Health Center

Inspectors wroteBased on interview and record review, the facility failed to honor a resident's advanced directive of choosing to have basic life support measures provided including cardiopulmonary resuscitation (CPR) for 1 of 1 resident (R34) reviewed during a closed record review. R34, whose advanced directive indicated he chose to have basic life support performed in the event of an emergency situation, was found unresponsive by facility staff. R34's activated health care power of attorney (HCPOA) was contacted, stated he did not wish CPR to begin, and facility staff members were instructed not to begin CPR on R34. R34 passed away at the facility. The facility's failure to provide basic life support, including cardiopulmonary resuscitation, to a resident who wished to be a full code, created a finding of immediate jeopardy that began on [DATE]. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect the total census of 30 residents. Residents (R) voiced concerns of food not being served at a desirable temperature (R132 and R133). 2 of 2 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility policy titled Food Production and Food Safety: Food Temperatures, dated 2023, includes in part: 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. A. Cooking temperatures must be reached and maintained according to regulations, laws and standardized recipes while cooking. B. Hot food items may not fall below 135 degrees Fahrenheit (F) after cooking . 2. [...]

Inspectors wroteBased on observation and interview, the facility did not distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 30 residents. Facility staff were observed touching multiple items in the kitchenette while serving and handling food without changing gloves or performing proper hand hygiene. Multiple cooks and dietary aide were observed dishing up lunch from the steam table with gloves on, stepping away from the steam table, touching other surfaces in the kitchenette, and returning to the steam table for meal plating with the same gloves on. Facility staff were also observed touching common surfaces in the kitchenette, then touching ready to eat foods while wearing the same pair of gloves. Cook E and [NAME] F were observed taking the food temperatures of several food items. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that there was a system in place for standard transmission-based precautions to be followed to prevent the spread of infections. This had the potential to affect all 30 residents. The facility failed to do the following: The facility had 14 residents and 9 staff that tested positive for COVID 19. The facility did not complete contact tracing or broad-based testing timely of all residents to identify if others were COVID positive. CNA L (Certified Nursing Assistant) worked for three (3) shifts while experiencing symptoms of cough, body aches, headache, and a sore throat. CNA L did not notify staff of his symptoms until they worsened while he was working at the facility. The facility is not utilizing source control timely on the affected unit. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that 4 of 4 sampled residents (R333, R5, R7, and R131) received treatment and care in accordance with professional standards of practice for foot care. The facility failed to ensure daily diabetic foot checks were completed for R333, R5, R7, and R131. As evidenced by: The facility does not have a policy for diabetic foot care. The current standard of practice per the American Diabetes Association copyright 1995-2024, https://diabetes.org, includes, in part: .1. Check your feet daily for sores, cuts, cracks, blisters, or redness . The facility follows PALTmed (Post- Acute and Long- Term Care Medical Association) standard of practice (SOP) dated 8/22/24, .Table 24. Suggested Elements of Comprehensive Monitoring for Patients with Diabetes Who Have Minimal Physical and Cognitive Impairments (emphasis intended) . Foot care: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents (R) receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 (R131) of 14 sampled residents. R131 voiced concern with not being able to put on her own compression stockings/TED (thrombo-embolic deterrent) hose, and that she was supposed to be wearing them daily, but that staff were not assisting her.

Inspectors wroteBased on interview and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 4 residents (R19) reviewed for PIs. R19 was admitted with a PI, the facility failed to obtain wound measurements for a 3-week period in June 2024 and 1 missed measurement in October 2024. Evidenced by: The facility policy titled Pressure Injury and Prevention approved on 6/2024 states in part .II. Determining the presence of a PI .E. Throughout stay in facility actions taken to continue ongoing evaluation of skin includes: 1. Weekly total body examination and documentation on the PCC (Point Click Care (electronic health record)) Nurse Advantage Skin Assessment or PCC Skin and Wound App (Application) . [...]

Inspectors wroteBased interview and record review the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 2 of 4 residents (R11 & R3) reviewed for limited range of motion (ROM) of 14 sampled residents. R3 is not receiving her restorative care per care plan. There are three different splint instructions for R11's splint for staff to follow making it difficult for staff to know which is the correct order. This is evidenced by: The facility policy entitled, Contracture Prevention and Treatment, dated 10/23, states, in part: . POLICY: It is the policy of this Company that each resident will be assessed for potential for developing contractures. Residents at risk will have a care plan for preventative intervention. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 sampled resident (R5) reviewed for dialysis. Facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis fistula site. This is evidenced by: The facility's policy titled Dialysis Services last revised on 8/2013 does not include an emergency plan. According to Clinical Journal of the American Society of Nephrology article titled Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies dated February 2017, .Vascular Access Hemorrhage: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were being offered nourishing snacks at bedtime daily when there is more than 14 hours between a substantial evening meal and breakfast the following day. This has the potential to affect 31 of 31 residents and 4 of 4 units. R14, R19, R2, R15, and R135 voiced concerns that residents were not consistently being offered a snack at bedtime. There was more than 14 hours between the evening meal and breakfast that facility staff were not offering snacks to all residents. This is evidenced by: The facility policy, entitled Meal Service, dated 8/23, states in part, .Resident (meal) service begins at the following times: breakfast 7:45 AM, dinner 11:45 AM, supper 4:45 (PM) . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all residents were able to formulate an advance directive, specifically related to code status, for 1 of 13 residents (R181) reviewed for code status. R181's most current code status preference form documents I do want CPR . (Cardiopulmonary Resuscitation, Full Code status) and his code status physician order and banner in the Electronic Health Record (EHR) indicate Do Not Resuscitate (DNR); these do not match. This is evidenced by: The Facility's Policy and Procedure titled Cardiopulmonary Resuscitation (CPR) - SNF (Skilled Nursing Facility), approved 1/2021, documents, in part: .Procedure .2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that they had all assessments and behavioral interventions in place for 1 of 5 residents reviewed for unnecessary medications out of a total sample of 16 Residents (R133). R133 does not have resident-centered behaviors for the Certified Nursing Assistants (CNA) staff to monitor. R133 receives antipsychotic medication and does not have an assessment for tardive dyskinesia AIMS (Abnormal Involuntary Movement Scale) or Discus. R133 receives medication for insomnia and does not have a sleep assessment completed. This is evidenced by: The Facilities Policy and Procedure entitled Psychotropic Medication Management dated 10/2023, documents, in part: .To ensure that resident drug regimen is free from unnecessary drugs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication rates of five percent or greater for 2 residents (R3 and R2) of six residents observed during medication pass. The facility had 28 opportunities and 2 medication errors resulting in 7.14% error rate. R3 has Physician Orders to receive Carvedilol with meals for hypertension. Surveyor observed RN C (Registered Nurse) administer R3's Carvedilol before the evening meal. This resulted in a medication timing error. R2 has Physician Orders to receive Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop into both eyes as needed for dry eyes admin QID prn (4 times per day as needed). Surveyor observed RN D (Registered Nurse) complete his checks during medication pass and voiced he was ready to administer medications. R2's artificial tears were expired. [...]