Capitol River Wellness & Rehabilitation

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain a comfortable and homelike environment. The facility census was 84. 1. Review of the facility policy titled, Maintenance Services, dated August 2020, showed the Maintenance Department is responsible for maintaining the building in compliance with current federal, state, and local, regulations, and guidelines. The Director of Maintenance is responsible for conducting regular inspections of hallways and activity areas. 2. Observation on 05/19/26 at 8:36 A.M., showed the memory care unit walls below the handrails, unpainted, and missing baseboard with exposed screws. 3. Observation on 05/19/26 at 10:56 A.M., showed the main dining walls with missing base trim, exposed unfinished and unpainted drywall. 4. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the residents and/or the residents' representative of the bed hold policy at the time of transfer to the hospital for eight residents (Resident #8, #12, #28, #47, #67, #71, and #86) out of 23 residents sampled. The facility census was 84. 1. Review of the facility policy titled, Bed Hold, dated June 2020, showed the facility notifies the resident or his/her representative, in writing, of the bed hold policy any time the resident is transferred to general acute care hospital. 2. Review of Resident #8's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and had not returned. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 3. [...]

Inspectors wroteBased on record review and interviews, facility staff failed to complete a baseline care plan within 48 hours of admission for six residents (Resident #8, #35, #62, #67, #71, and #86) out 23 sampled residents. The facility census was 84.1. Review of the facility's policy titled Care Planning, dated 06/2020, showed the Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission and will include at least the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. 2. Review of Resident #8's medical record showed staff documented the resident admitted to the facility on [DATE]. Review of the record showed a baseline care plan was not completed.3. Review of Resident #35's medical record showed staff documented the resident admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments for four residents (Resident #5, #9, #71, and #83) who used bed rails out of 23 sampled residents. The facility census was 84. 1. Review of the facility's policy titled Bed Rails, dated 06/2020, showed: -Before installing a bed rail, the facility must assess the resident for risk of entrapment from bed rails and ensure the beds dimensions are appropriate for the resident's size and weight; -Maintenance/Designee will assess the bed dimensions no less than quarterly; -Maintenance will also check bed rails regularly to ensure they are still installed correctly, as rails may shift or become loose over time. The facility policy did not address zone measurements for risk of entrapment. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure sanitary conditions for a urinary drainage bag (a bag attached to a tube that holds urine) when staff failed to keep the drainage bag off the floor for three residents (Resident #5, #58 and #34) out of three sampled residents. The Facility census was 84. 1. Review of the facility policy titled, Catheter-Care of, dated June 2020, showed catheter collection bags should always be kept below the level of the bladder, including during transport, avoiding contact with the floor. Take care to ensure the collection bag does not touch the floor at any time. 2. Review of Resident #5's Annual Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 03/06/26, showed staff assessed the resident with an indwelling urinary catheter. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure two resident's (Resident #1 and #2) were allowed to exercise resident's rights when staff opened their mail without the resident's present. The facility census was 81. 1. Review of facility's resident bill of right's policy, dated November 2016, showed residents have the right to send and receive mail promptly and unopened. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/12/25, showed staff assessed the resident as cognitively intact. During an interview on 4/28/25 at 10:00 A.M., the resident said the business officer manager (BOM) opened his/her mail in his/her office and then came in his/her room on 4/24/25. [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain professional standards of care, when staff failed to document they provided colostomy care for one resident (Resident #1), catheter care for one resident (Resident #2), monitor blood glucose levels for one resident (Resident #3), or obtain weights for one resident (Resident #4) out of four sampled residents. The facility census was 81. 1. Review of the facility's Colostomy Care policy, dated 08/2017, showed staff were directed to document on treatment sheet care completed. Review of the facility's Weights policy, dated 10/2009, showed staff were directed to electronically document weights. The facility did not provide a policy in regard to catheter care or blood glucose monitoring documentation guidance. 2. [...]

Inspectors wroteBased on observation, interviews and record review, facility staff failed to provide adequate nursing staff, as determined by their facility assessment. The facility census was 81. 1. Review of the Facility Assessment, dated 08/02/24, showed staff are directed as follows: -Direct care staff required to care for their facility census for an eight hour shift should include: Three day nurses, three evening nurses, three night nurses, six day Certified Nurse Aides (CNA's), six evening CNA's, five night CNA's, and two day shower aide's. -The assessment is based on the resident population and their healthcare needs and support; -The average daily census number of occupied beds was 88. Review of the employee staffing schedule from 02/01/25 through 02/28/25, with an average daily census of 88, showed: -Saturday 02/01/25- zero day shower aides, two evening nurses and five CNA's; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. The facility census was 85 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2016. showed: -Food shall be stored on shelves in a clean, dry area, free from contaminants; -Foods shall be stored at proper temperatures and using appropriate methods to ensure the highest level of food safety; -Label food items held for longer than 24 hours with the name of the food, if not in original packaging, and the date by which it should be sold,consumed or discarded; [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent the commingling of 32 resident's (Resident #8, #9, #12, #17, #19, #20, #21, #22, #23, #27, #32, #35, #39, #43, #44, #46, #49, #52, #60, #65, #71, #78, #87, #89, #90, #91, #92, #93, #94, #95, #96, and #97) personal funds with the facility operating funds out of 85 sampled. The sampled residents resided in the facility. The facility census was 85. 1. Review of the facility's policy titled Collections Guidelines, undated, showed: -Requests for a refund that is a result of a credit balance on the resident's account; -Resident refunds are requested based on the following; -When a resident has discharged the facility with no anticipation of returning; -When an overpayment of funds was applied to the account and a refund is requested by the resident or responsible party; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, and ceilings of resident occupied rooms and common areas. The facility census was 85. 1. Review of the facility's policy titled Housekeeping Cleaning Procedures: Resident Room Cleaning, dated June 2018, showed staff were directed as follows: -Dust mop and damp mop floor; -Damp mop restroom floor using microfiber flat mop; -Weekly procedure to remove mineral deposits from sink and tub/shower; -Wipe walls. Review of the [NAME] Side and East Side Housekeeper checklist, undated, showed staff were directed as follows: -Remove trash, sweep and mop, spot clean walls, sweep and mop room last and leave a wet floor sign; -Mondays- dust over head lights and blinds and bathroom fans; [...]

Inspectors wroteBased on observation and interview, facility staff failed to respect the dignity of two residents (Resident #22 and #24) out of 22 sampled residents during meal time. The facility census was 85. 1. Review of the policy titled The Dining Experience: Staff Roles, dated 2016, showed staff will be discouraged from standing over the resident while assisting them to eat and staff will promote resident dignity in the dining room. Review of the facility policy titled Resident [NAME] of Rights, reviewed January 2015, showed residents will be treated with consideration to respect, and full recognition to the residents dignity. 2. Observation on 12/16/24 at 8:46 A.M., showed Resident #22 and Resident #24 in the dining room at the same table. Observation showed Certified Nurse Aide (CNA) M placed meal trays in front of Resident #22 and Resident #24. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 87. 1. Review of the facility's Organizational Plan and Roles of Key Staff policy, dated 2016, showed The Director of Food and Nutrition Services credentials will follow state regulations. The Director of Food and Nutrition Services credentials may include a Sanitation Certification, a 90-hour approved Dietary Manager's Course, or a two or four year degree in nutrition or food service as approved by the state. Review of the dietary manager's (DM) personnel records, showed a hire date for the DM position listed as 11/19/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to reheat pureed food items in accordance with the standardized recipes to prevent the growth of food-borne pathogens and potential for food-borne illness. The facility staff also failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit (º F) or higher upon service to the residents. The facility census was 87. 1. Review of the facility's Monitoring Food Temperatures for Meal Service, dated 2016, showed: -Prior to serving a meal, food temperatures will be taken and documented for cold and hot foods to ensure proper serving temperatures. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. The facility staff failed to properly sanitize manually washed kitchenware to prevent cross-contamination. The facility staff failed to store food in a manner to prevent contamination and out-dated use. The facility staff also failed to maintain food delivery equipment in a clean and sanitary manner to prevent the growth of food-borne pathogens and prevent cross-contamination. The facility census was 87. 1. Review of the facility's Proper Hand Washing and Glove Use policy, dated 2016, showed: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, doors, door frames, trim, handrails, and windows in good repair. The facility census was 87. Review of the policies provided by the facility did not contain a policy for environmental concerns. 1. Review of the Maintenance Clipboard, showed it did not contain maintenance requests for the disrepair listed below. 2. Observation on 02/05/24 at 9:51 A.M., showed resident occupied room [ROOM NUMBER] bathroom door with chipped paint. Observation showed the corner by the bathroom with chipped paint and exposed drywall. 3. Observation on 02/05/24 at 9:56 A.M. showed the 100 Hall walls and handrails with black marks. Observation showed between room [ROOM NUMBER] and 106 trim with the wood chipped off. 4. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for nine residents (Resident #4, #6, #10, #31, #46, #58, #83, #92, and #302). The facility census was 87. 1. Review of the facility's policy, titled Comprehensive Person Centered Care Plans, dated March 2018, showed staff were directed: -Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -The comprehensive person centered care plan shall be fully developed within seven days after completion of the admission Minimum Data Set (MDS) Assessment, a federally mandated assessment tool to be completed by facility staff; [...]

Inspectors wroteBased on Based on observation, interview, and record review, facility staff failed to meet professional standards of care when staff failed to document neurological checks and fall follow-up for six residents (Resident #18, #46, #50, #58, #67, and #302), and failed to ensure physicians orders were followed for two residents (Resident #18, and #302). The facility census was 87. 1. Review of the facility's policy titled Accident and Incident Documentation and Investigation Resident Incident, revised 07/2018, showed staff are directed to do the following: -Licensed Nurse assigned at the time of the resident care accident/incident is responsible for documenting the incident in the resident's medical record; -Nurse's notes could contain the following documentation: Date and time of incident; Clear, objective facts of what happened; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow up on Urinalysis and Culture with Sensitivity (UA C&S) (lab work to rule out Urinary Tract Infection (UTI) and begin treatment timely for two residents (Resident #18 and #50). The facility census was 87. 1. Review of the facility's policy titled Surveillance for Healthcare Associated Infections, revised 09/2019, showed it is the responsibility of the Director of Nursing (DON), Infection Control Designee, Licensed Nurse to report suspected infections to the physician and obtain a diagnosis. Review of the facility's policy titled Laboratory Tests, revised 11/2017, directed staff as follows: -Lab tests are completed as ordered by the physician or physician extender (Nurse Practitioner (NP), Physician Assistant (PA), or Clinical Nurse Specialist (CNS)); [...]

Inspectors wroteBased on interview and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS), a federally mandated assessment tool, for one residents (Resident #67) when staff failed to accurately assess the residents' falls. The facility census was 87. 1. Review of the policies provided by the facility did not contain a policy for MDS assessments. 2. Review of the Resident Assessment Instrument (RAI) manual, dated 10/2023, showed staff are directed as follows: -Annual MDS Assessment Reference Date (ARD) must be set within 366 days of the previous comprehensive assessment; -Use the RAI manual to increase the accuracy of assessments; -Coding fall history on admission: look back 180 days prior to admission; -Coding a fall any time in the last month: code 0 for no fall; code 1 for a fall; code 9 for unable to determine; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to remove and destroy discontinued and outdated medications. The facility census was 87. Review of the facility's policy titled Medication Storage, dated November of 2010, showed outdated medications are to be removed from storage on a continual basis. 1. Observation on 02/07/24 at 10:45 A.M., showed the Memory Care Unit (MCU) medication cart contained: -PROAIR HFA (to treat or prevent bronchospasm) 90 Micrograms (mcg) Inhaler with an expiration of 02/2024; -Hydroxyzine HCL (Hydrochloride) 25 milligrams (mg) tablets, dated 09/12/22; -Hydroxyzine HCL 25 mg tablets with an expiration date of 09/16/23; -Prochlorperazine (treat nausea and vomiting)10 mg tablets, with an expiration date of 06/7/23; -Ondansetron (prevent nausea and vomiting) 4 mg tablets with an expiration date of 11/15/23; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide wound care in a manner to reduce the risk of infection for one resident (Resident #10). The facility census was 87. 1. Review of the facility's policy titled Hand Washing, revised 09/2019, showed staff were directed to use proper hand washing technique to prevent the spread of infection. 2. Review of Resident #10's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/29/23, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Rejection of care not exhibited; -Maximal assist from staff member for personal hygiene; -Stage 4 pressure ulcer; -Indwelling catheter; -Ocassionally incontinent of bowel; -Dependent on staff member for bathing. Observation on 02/05/24 at 10:22 A.M., showed the wound nurse entered in Resident #10's room to provide wound care. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify one resident's (Resident #1) responsible party when the resident had a fall with injury and transprted to the hospital for treatment. The facility was census 91. 1. Review of the facility's resident incident policy, dated July 2018, showed staff are directed to document any contacts made or attemptes made with the resident's physician, family, legal representative, or any other health care professional or person involved with the resident's care. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/23/23, showed staff assessed the resident as: -Severe Cognitive Impairment; -At risk for falls with a fall in the past two to six months prior to admission; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide 24-hour protective oversight for one sampled resident (Resident #1) when they failed to conduct visual checks on the resident on 09/22/23 from 6:45 P.M. to 8:26 A.M. At that time, staff found the resident in his/her room on the floor with blood on his/her hands and face. Hospital staff determined the resident suffered a fracture to the right sixth rib. Facility census was 93. The Administrator was notified on 9/27/23 at 4:23 P.M., of an Immediate Jeopardy (IJ) which began on 9/22/23. The IJ was removed on 9/24/23 as confirmed by surveyor onsite verification. 1. Review showed the facility did not have a policy on monitoring or rounding on residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to have adequate nursing staff available to meet the needs of the residents on the Memory Care Unit (MCU), as determined by their facility assessment. Review showed only one Nurse Aide (NA) worked on the MCU on the night shift of 9/22/23 responsible for the care of 23 residents during the shift when the facility assessment showed the general staffing plan for direct care staff would require a ratio of one staff to ten residents at the least, and a ratio of one staff to 20 residents at most. Facility staff did not check on one resident (Resident #1) who resided on the MCU at all during the night shift of 9/22/23 into 9/23/23. The facility census was 93. 1. Review of the Facility Assessment, dated 1/10/23, showed the number of staff required to care for their facility resident census as follows: [...]