CAPITOL LAKES HEALTH CENTER - MADISON, WI

Complaint Deficiency

• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Provide doctors orders for the resident's immediate care, at the time the resident was admitted
  • Harm: Actual harm
  • Scope: Few
• Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay
  • Harm: Potential for minimal harm
  • Scope: Many
• Exits that are accessible at all times
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Exits that are free from obstructions and can be used at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Proper stairway enclosures and vertical shafts
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Protected exits that allow the resident to escape the building
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Emergency lighting that can last at least 1 1/2 hours
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Did not have a written emergency evacuation plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A fire alarm system that can be heard throughout the facility
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• An approved automatic sprinkler system connected to the fire alarm system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly protected cooking facilities
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Exits that are free from obstructions and can be used at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly sized and located linen or trash receptacles
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Weekly inspections and monthly testing of generators
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Limit the charges against the personal funds of a resident for items or services for which payment is made under Medicare or Medicaid
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly installed hallway dispensers for alcohol-based hand rub
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide care by qualified persons according to each resident's written plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Did not have a written emergency evacuation plan
  • Harm: Potential for minimal harm
  • Scope: Many
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Potential for minimal harm
  • Scope: Many
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Potential for minimal harm
  • Scope: Many
• Back-up procedures in place for a faulty automatic sprinkler system
  • Harm: Potential for minimal harm
  • Scope: Many
• An approved back-up procedure for a faulty fire alarm system
  • Harm: Potential for minimal harm
  • Scope: Many
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give each resident enough fluids to keep them healthy and prevent dehydration
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• A two-hour-resistant firewall in common walls
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly maintained smoke detectors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• An approved automatic sprinkler system connected to the fire alarm system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly protected cooking facilities
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Weekly inspections and monthly testing of generators
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Keep each resident's personal and medical records private and confidential
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Allow residents to easily view the results of the nursing home's most recent survey
  • Harm: Potential for minimal harm
  • Scope: Many
• 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide care by qualified persons according to each resident's written plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Actual harm
  • Scope: Few
• Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Post nurse staffing information/data on a daily basis
  • Harm: Potential for minimal harm
  • Scope: Many
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Dispose of garbage and refuse properly
  • Harm: Potential for minimal harm
  • Scope: Many
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Train all employees on what to do in an emergency, and carry out announced staff drills
  • Harm: Potential for minimal harm
  • Scope: Many

Quality Measures

Staff Information