Capitol Lakes Health Center

In the surveyor’s words

From the most serious findings on record at Capitol Lakes Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Mar 10, 2026

  Based 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. […]

• Actual harm, isolatedF580Jun 21, 2023

  Based on interview and record review, the facility did not ensure that the resident's physician was consulted when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 35 residents (R1.) R1 had a change of condition during the night shift on 3/29/23 following a fall that occurred on the late afternoon of 3/28/23. The facility did not consult R2's physician in a timely manner. This is evidenced by: The facility policy entitled, Change in Condition, with revision date of 6/21, states, in part: . PROCEDURE: . The Licensed Nurses will notify the physician, the resident and or resident's responsible party when there is a change of condition and will document such notification in the health record . […]

• No harm, potential for more than minimal, widespreadF804Nov 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Nov 6, 2024

  Based 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. […]