Cape Heritage Rehabilitation & Health Care Center

In the surveyor’s words

From the most serious findings on record at Cape Heritage Rehabilitation & Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 5, 2022

  Based on observations, interviews, record review, and policy review, the facility failed to ensure adequate supervision and develop and implement fall interventions for one Resident (#4), out of a sample of 19 residents, resulting in a fall with major injury. Findings include: Review of the facility's policy titled Falls Management, last revised August 2018, included but was not limited to: -The facility will utilize all resident/patient related information made available upon admission and ongoing to determine resident/patient at-risk for fall status. […]

• Actual harm, isolatedF692Oct 5, 2022

  Based on interviews and record review, the facility failed to monitor the nutritional status of two Residents (#43 and #42), out of a total sample of 19 residents. Specifically, the facility 1. Failed to monitor the weight loss of Resident #43, resulting in a significant weight loss; and 2. Failed to implement nutritional interventions for Resident #42. Findings include: 1. Review of the facility's policy titled Weights, dated August 2015, indicated the following residents would be weighed weekly for four weeks: -residents with unanticipated weight loss of more than 5% in one month -all residents with significant weight loss are reviewed by the interdisciplinary team and interventions implemented as appropriate and are monitored weekly -a weight loss/gain of 5 pounds or more on a… […]

• Actual harm, isolatedF725Oct 5, 2022

  Based on interviews and record reviews, the facility failed to ensure there was sufficient staff available to provide nursing services and care required to meet the needs of two Residents (#43 and #40), in a total sample of 19 residents. Specifically, the facility failed 1. For Resident #43, to ensure weekly weights were obtained to monitor weight loss, resulting in significant weight loss; and 2. For Resident #40, to ensure wound care was provided as ordered. Findings include: 1. Resident #43 was admitted to the facility in January 2019 with a diagnosis of Parkinson's disease. […]

• No harm, potential for more than minimal, widespreadF814May 21, 2025

  Based on observation and staff interview, the facility failed to ensure that trash, garbage, and refuse were disposed of and properly contained within a receptable constructed with a tight-fitting lid. Findings include: Review of the 2022 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) by the U.S. Food and Drug Administration (FDA) indicated outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. […]

• No harm, potential for more than minimal, widespreadF908May 21, 2025

  Based on observation and interview, the facility failed to ensure mechanical equipment in the main kitchen was maintained in a safe operating condition, specifically (1) the walk-in freezer, (2) the stove hood, and (3) the ice machine. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. 1. […]