Inspection visit
Inspection
Citations
16 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F678 - Personnel provide basic life support, including CPR, to a resident
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0131GeneralS&S Dpotential for harm
Meet requirements for sections of health care facilities separated by fire resistive construction.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0541GeneralS&S Dpotential for harm
Install properly constructed and protected linen or trash chutes.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the August 11, 2022 survey of CAPITOL LAKES HEALTH CENTER?
This was a inspection survey of CAPITOL LAKES HEALTH CENTER on August 11, 2022. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CAPITOL LAKES HEALTH CENTER on August 11, 2022?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.