Capri Health and Rehabilitation Center

Inspectors wroteBased on record review, interview, and observation, the facility failed to implement policies and procedures to investigate allegations of abuse and neglect for 1 of 2 (#1) residents sampled.

Inspectors wroteBased on observation and interview, the facility failed to ensure housekeeping and maintenance services to maintain a safe, functional, sanitary and comfortable environment for residents, staff and the public on the first and second floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a resident centered care plan to meet the needs of 1 (Resident #45) of 3 residents reviewed with impaired hearing.

Inspectors wroteBased on observation, review of the clinical record, review of facility policy, resident and staff interviews, the facility failed to consistently apply a physician ordered orthotic device to prevent the decline in range of motion for 1 (Resident #32) of 1 resident reviewed with contractures (rigidity of joint).

Inspectors wroteBased on observation, review of facility policy and procedures, record review, staff and resident interviews, the facility failed to provide the necessary care and services to meet the needs for 3 (Resident #999, #875 and #900) of 5 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on record review, review of facility policy and procedures and resident and staff interviews the facility failed to ensure pain medications were provided in accordance with professional standards of practice and physician orders for 2 (Resident #99 and #399) of 3 residents reviewed for pain management.

Inspectors wroteBased on observation, review of facility policy and procedures and staff interview, the facility failed to provide a clean, safe and sanitary environment for residents in 6 (Rooms 110, 113, 114, 116, 118 and 119) of 17 rooms observed on the Memory Care Unit.

Inspectors wroteBased on review of facility policy and procedures, record review, staff and resident interviews, the facility failed to provide the necessary care and services to ensure each resident who is incontinent of urine is identified, assessed and provided appropriate incontinent care for 2(Resident #999 and #900) of 3 residents reviewed with incontinence.

Inspectors wroteBased on observation, review of facility policy and procedures, review of clinical records and staff and resident interview, the facility failed to secure all medications in a locked storage compartment and failed to ensure 1 medication cart (East wing) of 5 medication carts was secured and locked when out of the direct supervision of the nurse.

Inspectors wroteBased on observation, clinical record review, policy and procedures review, staff and resident interviews the facility failed to protect residents' rights to be free from verbal and physical abuse for 3 (Residents #700, #650, and #800) of 3 sampled residents.

Inspectors wroteBased on record review, and interview the facility failed to report significant changes in behaviors to the appropriate state agencies for a level II Preadmission Screening and Resident Review (PASRR) for 1 (Resident #999) of 3 residents reviewed with newly diagnosed psychiatric disorder.

Inspectors wroteBased on record review and staff interview the facility failed to ensure clinical records contained complete and accurate documentation of care provided for 2 (Residents #1 and #3) of 3 residents reviewed for accuracy of clinical records.

Inspectors wroteBased on record review, review of facility's policy and procedure, staff, and resident interview the facility failed to implement a systemic approach to identify risk factors and implement appropriate interventions to prevent avoidable fall related serious injuries for 5 (Resident #20, #85, #193, #392, and #292) and 2 (Resident #27, and #192) with multiple falls, of 10 residents sampled with falls or fall related injuries. Resident #20 was admitted to the facility on [DATE] and was dependent on staff for repositioning. On 1/22/22 the resident rolled out of bed during care and sustained a nasal bone fracture. Resident #85 was admitted to the facility on [DATE] and was assessed to be at risk for falls. On 2/5/22 and 5/14/22 the resident sustained a fall resulting respectively in a fractured hip and wrist and acute head injury. [...]

Inspectors wroteBased on record review, staff, and resident interview the facility administration failed to use its resources effectively to ensure consistent and ongoing implementation of effective measures to prevent avoidable falls and fall related injuries. Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right hip fracture. On 1/10/22 the resident sustained a fall resulting in dislocation of the right hip prosthesis. On 1/22/22 Resident #20 sustained a nasal bone fracture when she was improperly turned in bed and fell. Resident #85 sustained multiple falls at the facility on 1/28/22, 2/5/22, 3/26/22, 3/30/22 and 5/14/22. On 2/5/22 Resident #85 was diagnosed with a left femoral neck, and left wrist fracture, left facial abrasion and contusion. On 5/14/22 Resident #85 was sent to the hospital after the fall and diagnosed with an acute head injury. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to prevention of avoidable falls and fall related serious injuries. On 1/22/22 Resident #20 sustained a nasal bone fracture when she was improperly turned in bed and fell. Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right hip fracture. On 1/10/22 the resident sustained a fall resulting in dislocation of the right hip prosthesis. Resident #85 sustained multiple falls at the facility on 1/28/22, 2/5/22, 3/26/22, 3/30/22 and 5/14/22. On 2/5/22 Resident #85 sustained a fall, was sent to the hospital and diagnosed with a left femoral neck fracture, left wrist fracture, left facial abrasion and contusion. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure a safe, functional, and comfortable environment for residents in 9 (room [ROOM NUMBER], 226, 227,228, 229, 231, 232, 239, 230) of 31 rooms observed by failure to store personal items in a sanitary manner, failure to repair walls and peeling wallpaper, failure to secure exposed cable wires.

Inspectors wroteBased on interviews and record reviews, the facility failed to report alleged violations which could constitute neglect, resulting in serious bodily injury for 4 residents (#20, #85, #292, and #392) of 9 residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure sufficient staffing to provide nursing and related services to assure resident safety and highest practicable physical and mental well-being for 5 residents (#60, #56, #16, #34 and #20) of 19 residents reviewed.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to ensure the safe storage of medications left at residents' bedside for 3 (Resident #144, #62 and #20) of 3 residents observed with unsecured medications at the bedside.

Inspectors wroteBased on observation, review of facility policy and procedure and staff interviews, the facility failed to label and date food in 1 (first floor) of 2 nourishment rooms. The facility failed to ensure food was prepared in a sanitary manner. The failure to label and date foods stored in the refrigerator can cause residents to consume food that may have expired.

Inspectors wroteBased on observation, record review, review of policy and procedure, resident and staff interview, the facility failed to have documentation of an interdisciplinary evaluation to determine the ability to safely self-administer medications for 1 (Residents #144) of 3 residents observed with unsecured medications at the bedside.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of discharge status, fall and elopement device use for 2 (Resident #94 and #52) of 13 reviewed for MDS accuracy.

Inspectors wroteBased on observation, record review, staff and resident interview, the facility failed to ensure 1 (Residents #80) of 1 resident's activity program reviewed had received and/or engaged in their activities of choice as identified in their activity/recreational assessment. The failure to ensure each resident is engaged in an activity program of their choice has a potential to cause loneliness and mental anguish for the resident.

Inspectors wroteBased on record review, review of facility's policy and procedure, and staff interview, the facility failed to have documentation of consistent and accurate monitoring of fluid intake for 1(Resident #56) of 1 resident with a physician's ordered fluid restriction.

Inspectors wroteBased on resident and staff interviews and record review the facility failed to ensure they maintained ongoing communication between the nursing facility and the dialysis center related to the ongoing assessment of a dialysis resident before, during, and after each dialysis treatment for 2 Residents (#25 and #34) of 2 residents receiving dialysis.

Inspectors wroteBased on record review, review of facility policy and procedure and staff interviews, the facility failed to ensure 2 licensed Practical Nurses (LPN) (LPN E and LPN F) of 4 LPN nursing staff had the appropriate competencies and skill set to administer intravenous (IV) medications.

Inspectors wroteBased on record review, policy review and staff interviews, the facility failed to act on consultant pharmacy recommendations for 1 (Resident #17) of 5 residents reviewed for unnecessary medications. This has the potential for delay of treatment and use of unnecessary medications.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the required up-to-date nurse staffing information was posted and readily available to residents and visitors.

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to provide a safe, sanitary, and homelike environment as evidenced by dry wall damage in residents' rooms on the second floor, ceiling tile and wall damage in the second floor shower room and a broken elevator button. Failure to identify and complete needed repairs could cause a safety and sanitary hazards to vulnerable residents.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to have documentation in the residents' medical record the physicians and/or nurse practitioners reviewed and addressed the pharmacist's recommendations for 2 (Residents #1 and Resident # 2) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, diet census report, facility provided menu for review, and staff interview, the facility failed to ensure 10 (Residents #2, #13, #25, #32, #39, #44, #51, #275, #276, and #324) of 10 residents received a wheat roll for lunch. The failure to follow the menu could potentially cause significant unintentional weight loss.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide urinary bag covers to promote resident dignity for 2 (Residents #275 and #276) of 2 residents reviewed.

Inspectors wroteBased on observation, clinical record review, staff interview, the facility failed to have documentation of observation, and monitoring of a dialysis access site for 1 (Resident #8) of 1 dialysis resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct accurate reconciliation between the electronic medication administration record (eMAR) and the Controlled Substance Record for 3 (Residents #11, #28, and #72) of 3 sampled residents reviewed.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure psychoactive medications were monitored and reduced when the behaviors were not exhibited in an attempt to discontinue the medications, and the facility failed to ensure the drug regimen was free from unnecessary medications for 1 (Resident #1) of 5 sampled residents reviewed for unnecessary medications.