Capital Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Consultant Pharmacist interviews, the facility failed to ensure a physician order for an as needed (PRN) psychotropic medication was time limited in duration for 1 of 5 residents reviewed for unnecessary medications (Resident #90).The findings included:Resident #90 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder.The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #90 was cognitively intact and was coded for use of an antianxiety medication.Resident #90 had an active physician order dated 7/19/25 for lorazepam oral tablet 0.5 milligram (mg). Give 0.5 mg by mouth two times a day for anxiety; give after breakfast AND give 0.5 mg tablet by mouth every 12 hours as needed (PRN) for anxiety. The order did not have a stop date.The care plan last reviewed on 7/28/25 revealed Resident #90 used anti-anxiety medication and was at risk for adverse side effects with an intervention for the Consulting Pharmacist to review the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews, the facility failed to consistently complete a thorough weekly pressure ulcer assessment that included the type of injury (pressure versus non pressure), pressure ulcer stage, a description of the pressure ulcer characteristics, presence of pain, and description of dressing or treatment for 1 of 2 residents observed for pressure ulcers (Resident #3). The findings included:Resident #3 was admitted to the facility on [DATE] with diagnoses which included functional quadriplegia and cerebral palsy. The Weekly Pressure Ulcer Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had one unhealed pressure ulcer to the sacrum, not staged, with measurements of 1 centimeter (cm) x 1 cm x 0.1 cm (length x width x depth). The wound bed was noted to have 100% granulation (new tissue that forms on the wound during healing process) tissue, with no odor. Resident #3 had a physician order in place dated 5/08/25 to apply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Consultant Pharmacist interviews, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving an antipsychotic medication, which is used for medication monitoring of side effects of antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #82).The findings included:Resident #82 was admitted to the facility on [DATE] with diagnoses which included vascular dementia without behavioral disturbances.The Mental Health and Antipsychotic Review (which included the AIMS assessment) completed on 12/26/24 revealed Resident #82 had no negative findings related to the use of antipsychotic medication and was categorized as low risk for movement disorders.The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #82 had severe cognitive impairment and was coded for the use of antipsychotic medication.The care plan last reviewed on 6/27/25 revealed Resident #82 received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident, staff, family, and physician (MD) interviews, the facility failed to provide care in a safe manner when Resident #3, who was positioned onto her right side at the edge of her bed and was left unattended by MD #1 during wound care. Resident #3 fell from her bed and required transfer to the hospital for medical evaluation. This was for 1 of 3 residents (Resident #3) reviewed for accidents. Findings included: Resident #3 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (disruption in blood supply to the brain which causes tissue damage). A review of Resident #3's comprehensive care plan revealed a focus area dated as initiated on 3/18/21 of actual fall with risk for further falls related to poor balance and unsteady gait. An intervention was to anticipate Resident #3's needs as much as possible. A review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She had no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, the facility failed to revise the care plan in the areas of behaviors (Resident #13) and hospice services (Resident #14) for 2 of 21 residents reviewed for care plan revision. The findings included: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, dementia, delusional disorder, and iron deficiency anemia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #13 had adequate vision without corrective lenses, had severe cognitive impairment, and required supervision for eating. Resident #13 was not coded for behaviors. The care plan last revised on 3/20/24 revealed no care plan for Resident #13's behavior related to the ingestion of non-edible substances and to keep bath items out of Resident #13's reach. The nursing progress note dated 4/04/24 at 12:01 am by Nurse #1 revealed Resident #13's vital signs were obtained, and Nurse Practitioner #1 was notified of Resident #13's incident.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, Wound Provider interview, Nurse Practitioner interview, and Medical Director interview, the facility failed to obtain a treatment order prior to treating a wound for 1 of 4 residents reviewed for professional standards of practice (Resident #251). The findings included: Review of the hospital medication administration record dated 6/28/24 revealed Resident #251 received honey 80% gel treatment to the right lower extremity prior to discharge to the facility. Review of the hospital discharge summary revealed Resident #251 was discharged to the facility on 6/28/24 with diagnoses which included cellulitis of the right lower extremity. The hospital discharge summary did not include wound treatment orders for the right lower extremity cellulitis. Resident #251 was admitted to the facility on [DATE] with diagnoses which included cellulitis (infection) of the right lower extremity and diabetes. The nursing admission review note completed on 6/28/24 by Nurse #5 revealed Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and interview with the Wound Care Physician the facility failed to transcribe Physician treatment orders and failed to implement the Wound Care Doctors orders as ordered for one (Resident #38) of three residents reviewed for pressure ulcers. The findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses that included stroke with hemiplegia, chronic atrial fibrillation, diabetes mellitus, hypothyroidism, and epilepsy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was cognitively impaired and was receiving treatments for a pressure ulcer. Review of Resident #38's care plan revealed she had a pressure ulcer on her coccyx and was at risk for development of additional pressure ulcers due to decreased ability to re-position and incontinence. bowel/bladder incontinence. Interventions included Apply moisture barrier with each brief change and prn, and administration of treatments as ordered by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, Nurse Practitioner interview, Medical Director interview, and Poison Control interview, the facility failed to provide a hazard free environment to prevent an avoidable accident when a resident with severe cognitive impairment (Resident #13) ingested an unknown amount of nontoxic liquid perineal and skin cleanser that was left within the resident's reach for 1 of 4 residents reviewed for supervision to prevent accidents (Resident #13). The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, dementia, delusional disorder, and iron deficiency anemia. Resident #13 had no known drug or food allergies. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #13 had adequate vision without corrective lenses, had severe cognitive impairment, and was not coded for behaviors. Resident #13 had no range of motion limitation for upper or lower extremities, required supervision or cueing for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to document wound treatment orders for 1 of 4 residents reviewed for medical record accuracy (Resident #251). The findings included: Resident #251 was admitted to the facility on [DATE] with a diagnosis of cellulitis (infection) of the right lower extremity. The nursing admission review note completed on 6/28/24 by Nurse #5 revealed Resident #251 was admitted to the facility on [DATE] with right lower extremity cellulitis and had two open areas to the right lower leg. The weekly skin assessment dated [DATE] completed by Nurse #5 revealed Resident #251 had an open area to the right lower leg. Nurse #5 noted that treatment was in place for the right lower leg open areas. An attempt to interview Nurse #5 via telephone on 7/17/24 at 9:30 am was unsuccessful. Review of the Treatment Administration Record (TAR) for June 2024 revealed no documentation that treatments were ordered or completed for Resident #251's right lower extremity wound. Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to administer enteral feeding formula at the correct rate as ordered by the physician for 1 of 1 resident (Resident #4) reviewed for enteral feedings. Findings included: Resident #4 was admitted to the facility on [DATE]. Diagnoses included dysphagia (difficultly swallowing) and gastrostomy (opening of the stomach) for enteral feedings. The revised care plan dated 9/14/2022 indicated Resident #4 required enteral feedings to assist her in maintaining or improving her nutritional status. Interventions included administering enteral feeding formula as ordered by the physician. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 received enteral feedings for nutrition for greater than 51% of total calories. Dietary notes dated 2/9/2023 recorded Resident #4 was receiving an enteral feeding at 40 milliliters (mL) per hour (hr) and increased the enteral feeding to 50 mL/hr due to weight loss. Physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.