Capitol Lakes Health Center

Inspection findings

1. Mar 10, 2026 Health · 11 findings
   • Serious Scope/severity J

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Mar 31, 2026 · CMS fire safety

2. Nov 6, 2024 Health · 17 findings
   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0687 Quality of Life and Care Deficiencies

     Provide appropriate foot care.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0541 Services Deficiencies

     Install properly constructed and protected linen or trash chutes.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Dec 6, 2024 · CMS fire safety

3. Oct 5, 2023 Health · 13 findings
   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Nov 3, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Nov 3, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Nov 3, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0809 Nutrition and Dietary Deficiencies

     Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

     Corrected Nov 3, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0131 Construction Deficiencies

     Meet requirements for sections of health care facilities separated by fire resistive construction.

     Corrected Dec 19, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Oct 23, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Oct 23, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Oct 16, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Oct 23, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Oct 18, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Oct 18, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Oct 23, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Oct 26, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BISHOP, RICHARD — corporate officer, NOT APPLICABLE, since 10/01/2021
• CENTER, SUE — corporate officer, NOT APPLICABLE, since 06/21/2017
• CONROY, TIMOTHY — w-2 managing employee, NOT APPLICABLE, since 03/23/2009
• DREW, SALLY — corporate director, NOT APPLICABLE, since 10/10/2016
• JOHANNSEN, STEPHEN — corporate officer, NOT APPLICABLE, since 01/16/2019
• NORRBOM, CLAY — corporate officer, NOT APPLICABLE, since 11/17/2017
• PETERSON, HARRY — corporate officer, NOT APPLICABLE, since 06/21/2017
• SHOLTY, ERIC — corporate officer, NOT APPLICABLE, since 05/27/2018
• KBC BANK NV — 5% or greater security interest, NOT APPLICABLE, since 01/01/2022
• LAPIS MUNICIPAL OPPORTUNITIES FUND III LP — 5% or greater security interest, NOT APPLICABLE, since 01/01/2022
• PACIFIC RETIREMENT SERVICES INC — operational/managerial control, NOT APPLICABLE, since 04/01/2008