Capitol Rehabilitation and Healthcare Center

Inspectors wroteBased on facility policy review, clinical record review, review of facility documentation, and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for six of 24 residents reviewed (Residents 5, 6, 7, 8, 9, and 10).

Inspectors wroteBased on review of facility policy, document review, and resident and staff interviews, it was determined that the facility failed to provide a resident the right to voice a grievance to the facility and make prompt efforts by the facility to resolve the grievance for one of four residents reviewed (Resident 4).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for three of four residents observed on contact precautions (Residents 1, 2, and 3).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of one residents reviewed for self-administration of medications (Resident 103).

Inspectors wroteBased on facility policy review, review of select employee files, and a staff interview, it was determined that the facility failed to verify if individuals have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property for four of five employee files reviewed (Employees 5, 6, 7, and 8).

Inspectors wroteBased on observations, facility policy reviews, and staff interviews, it was determined that the facility failed to properly label drugs in one of three medication carts observed (North Unit West); failed to store medications properly in one of three medication carts observed (North Unit West); and failed to discard expired medications in one of three medication carts observed (Guild Unit) and one of two medication rooms observed (South Unit). Findings Include: Review of facility policy, titled Administering Medications, dated April 2019, revealed, in part, 13. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of facility policy, titled Medication Labeling and Storage, dated February 2023, revealed, in part, 5. [...]

Inspectors wroteBased on observations, document review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on one of three nursing units (three shower rooms on the north unit and one resident bathroom on the north unit).

Inspectors wroteBased on observations, facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 30 residents reviewed (Residents 5 and 84). Findings Include: Review of facility policy, titled Care Plans, Comprehensive Person-centered, revised March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of facility policy, titled Isolation- Categories of Transmission-Based Precautions, revised September 2022, failed to reveal any expectation of adding transmission-based precautions to a resident's care plan. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide care and services necessary for care dependent residents for two of five residents reviewed (Residents 1 and 2). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs) and hypertension (high blood pressure). Review of Resident 1's comprehensive care plan under the focus section for Activities of Daily Living (ADL), revealed an intervention that Resident 1 required total assistance with eating and drinking, initiated on June 25, 2025. Further review of Resident 1's care plan, under the focus section for nutrition, revealed an intervention to provide feeding assistance at meals, initiated on April 18, 2024. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of five residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs) and hypertension (high blood pressure). Further review of Resident 1's clinical record revealed that the Resident had a stage 4 pressure ulcer on the sacral region. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 10 residents reviewed (Resident 2).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for one of six residents reviewed (Resident 1).

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to document physician ordered medication administrations in the clinical record for one of seven residents reviewed (Resident 6).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of five residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's comprehensive plan of care for one of five residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 25 residents reviewed (Residents 11, 17, 91, and 101).

Inspectors wroteBased on facility policy review, observation, clinical record review, and resident representative and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 25 residents reviewed (Residents 65, 102, 106, and 113), and failed to give the opportunity to participate in the development, review, and revision of his/her care plan for four of 25 residents reviewed (Residents 41, 73, 91, and 101).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice when administering medications for five of 22 residents reviewed on the East Wing (Residents 11, 21, 43, and 55), and that physician orders are discontinued for one of 25 residents reviewed (Resident 99). Findings Include: Review of Resident 11's clinical record revealed diagnoses that included hypothyroidism (thyroid doesn't produce enough thyroid hormone) and age-related osteoporosis (occurs when bones become weaker and more fragile due to the aging process). A review of Resident 11's clinical record revealed she was ordered Levothyroxine 75 mcg (micrograms) daily at 6:00 AM. [...]

Inspectors wroteBased on facility policy review, clinical record review, facility document review, and resident and staff interviews, it was determined that the facility failed to administer the correct dosage of medication for one of 25 residents reviewed (Resident 41); and failed to ensure that physician's orders were implemented for three of 22 residents on the East Wing (Residents 69, 87, 89).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed for dialysis (Resident 77).

Inspectors wroteBased on observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records are in order and that account of all controlled drugs is maintained and periodically reconciled for three of three residents reviewed (Resident 63, 117, and 119).

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of four residents reviewed for pressure ulcers (Resident 91).

Inspectors wroteBased on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to monitor hydration status precisely and effectively for one of 25 residents reviewed (Resident 14).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for five of 28 residents reviewed (Resident 17, 35, 39, 94, and 119). Findings Include: Review of Resident 17's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems) and dependence on supplemental oxygen (cannot live with supplemental oxygen). Review of Resident 17's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 26, 2023, Section O0100. Special Treatments, Procedures, and Programs, C1. Oxygen Therapy revealed that Resident 17 did not receive oxygen therapy during the previous 14 days. [...]

Inspectors wroteBased on clinical record review, observations, and staff and resident interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for five of 28 residents reviewed (Resident 113, 335, 371, and 372).

Inspectors wroteBased on observations, review of meal extension sheets (forms that reveal what foods and quantities should be served to each diet), and staff and resident interviews, it was determined that the facility failed to ensure therapeutic diets (meal plans that control the intake of certain foods or nutrients) were provided for the lunch meal on December 20, 2023.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one of 28 residents reviewed (Resident 330).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 26 residents reviewed (Residents 3 and 113).

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive services consistent with professional standards of practice and the comprehensive person-centered care plan for one of one resident reviewed (Resident 80).

Inspectors wroteBased on surveyor observation, facility policy review, and staff interview, it was determined that the facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards, including refrigeration, for one of two medication rooms observed (South Hall). Findings Include: Review of facility policy titled, Medication Labeling and Storage, with revision date of February 2023, revealed Multi-dose vials that have been opened or acceded (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. [...]

Inspectors wroteBased on review of resident council meetings and resident grievance, completion of meal test tray, review of select facility test tray form, and resident and staff interviews, it was determined that the facility failed to provide foods that were at appetizing temperatures at one of one meals.

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by wearing required PPE (personal protective equipment) on two of three employees observed (Employees 1 and 2). Findings Include: Review of facility policy, titled Isolation - Categories of Transmission-Based Precautions, with a revision date of September 2022, revealed in a section labeled Contact Precautions, 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). 8. [...]