Medilodge of Capital Area

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 115 residents who consume food products, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 115 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteThis citation pertains to intakes: 2969859, 2990774, 2999197, 2999242 Based on observation, interview and record review, the facility failed to protect and prevent abuse in four residents (R12, R34, R95, R101) of four residents reviewed for abuse and six residents (R12, R34, R61, R68, R95, R101) of six residents reported from facility reported incidents. Findings Include: Resident #12 (R12): Per the facility's face sheet R12 was admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnoses included depression and anxiety. Review of a Brief Interview of Mental Status (BIMS) score dated 5/5/2026 revealed R12 scored a 15 out of 15 which indicated full mental cognition. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. Findings Included:On 06/26/2026 at 02:07 p.m. an interview was conducted with Nursing Home Administrator (NHA) A regarding concerns identified during the current Recertification Survey. NHA A' explained that during the last year the QAPI committee had identified areas of concerns for Performance Improvement Plans (PIPS). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two witness signatures were obtained when the Responsible Party signed a do-not-resuscitate (DNR) document for one (R100) of one reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's health information was kept private for one (R24) of one reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for three residents (R34, R68, R107) of six reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately investigate an allegation of neglect/abuse for two resident (#34, #107) of six residents reviewed for neglect/abuse. Findings Included: R107A review of the clinical record revealed R107 was admitted into the facility on 9/26/25 with diagnoses that included: Bipolar disorder, adjustment disorder with mixed disturbance of emotions and conduct and depression. According to the Minimum Data Set (MDS) assessment dated [DATE], R107 scored 6/15 on the Brief Interview for Mental Status exam (which indicated severely impaired cognition). On 6/23/26 at 1:02 PM, R107 was observed sitting on his bed in his room. R107 reported that he kissed a staff member and that staff member kissed him back. He identified the staff member as CNA (certified nursing assistant) P and reported that facility staff are aware. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for two (R3 and R121) of 23 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accuracy of comprehensive the care plan for 1 (Resident 12) of 23 reviewed.

Inspectors wroteBased on interview and record reviews the facility failed to include one resident (R76) out of two residents reviewed for scheduled outings with the activity group with the potential of social isolation and not living her highest practicable, physical, mental, and psycho-social wellbeing. Findings Included;Resident #76 (R76)Review of the medical record revealed R76 was admitted to the facility 02/13/2026 with diagnoses that included Dementia, heart failure, diabetes mellitus 2, anxiety, and senile degeneration of the brain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2026, revealed R76 had a Brief Interview for Mental Status (BIMS) of 03 (severe cognitive impairment) out of 15. During an observation and interview on 06/25/2026 at 11:01 AM, R76 was sitting up in the front lobby looking out the window. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide restorative therapy services for one (Resident 24) of one reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control standards and manufacture recommendations were followed for disinfecting a glucometer (medical device used to measure the approximate concentration of sugar in blood) for one resident (#71) of one residents reviewed during medication administration. Findings Included:Resident #71 (R71)Review of the medical record revealed R71 was admitted to the facility 07/17/2025 with diagnoses that included atherosclerotic heart disease (fatty plaques build up in coronary arteries), type 2 diabetes, heart failure, dementia, aortic (valve) stenosis (abnormal narrowing), gastro-esophageal reflux, insomnia, hyperlipidemia (high fat content in blood), anemia (low red number of red blood cells), atrial fibrillation, and hypertension. [...]

Inspectors wroteThis citation pertains to Intake 2788552. Based on interview and record review, the facility failed to ensure a physician documented that transfer/discharge was necessary for one (R1) of three reviewed.

Inspectors wroteThis citation pertains to Intake 2747733. Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a vendor for one (R3) of three reviewed. Findings Include:Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included major depressive disorder and history of traumatic brain injury. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/26 revealed R3 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R3 discharged from the facility on 2/19/26. Review of the incident investigation that the facility reported to the State Agency revealed Background: [R3] was admitted on [DATE]. On 2/8/26, the physician ordered an x-ray for [R3]. [Xray Technician (XT) E] .came into the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report allegations of abuse to the State Agency for four residents (#1,#6,#9,#10) of ten residents reviewed for abuse. This citation pertains to intake #2615129 Review of the medical record reflected R1 was admitted to the facility on [DATE], with diagnoses that included alcohol dependance and anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/29/25, reflected R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an interview on 9/23/25 at 9:30 AM, Family Member (FM) D reported concerns that R1's debit card was removed from the facility by staff and used to purchase items. Additionally, the staff member had withdrew cash from the bank and kept some for themselves. The staff member was identified as CNA E. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate allegations of abuse for three residents (#6,#9,#10) out of ten residents reviewed for abuse. Findings Included: Resident #6 (R6)Review of the medical record revealed R6 was admitted to the facility 08/07/2025 with diagnoses that included type 2 diabetes, chronic kidney disease, anemia (low red blood cells, hyperlipidemia (high fat content in blood), gastro-esophageal reflux, dementia and depression. The most recent Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 08/13/2025, revealed R6 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its own written policies and procedures for Abuse and Neglect for four residents (#6, #9, #10) of 10 residents reviewed. Findings Included:Resident #6 (R6):Review of the medical record revealed R6 was admitted to the facility 08/07/2025 with diagnoses that included type 2 diabetes, chronic kidney disease, anemia (low red blood cells, hyperlipidemia (high fat content in blood), gastro-esophageal reflux, dementia and depression. The most recent Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 08/13/2025, revealed R6 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician order an advanced directive/ Do Not Resuscitate, for one resident (resident #8) of one reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a change in condition, Minimum Data Set (MDS) Assessment for two (Resident #6 and Resident #15) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, record review, the facility failed to update/revise individualized, person-centered care plans to reflect the changing care needs for 1 resident (R5) of 23 residents reviewed for care plans, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activity of daily living skills were maintained for one of five residents reviewed (Resident #74).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of facility-acquired pressure ulcer injuries for one resident (R5) of three residents reviewed, resulting in facility-acquired (in-house) development of pressure ulcer/injuries, pain, discomfort, and likelihood for prolonged illness or hospitalization.

Inspectors wroteThis citation pertains to intake MI00151282 Based on observation, interview, and record review the facility failed to serve food at the preferred temperature for two resident (#2, #4) of three resident reviewed for food palpability resulting in dissatisfaction during meals. Findings Included: Resident #2 (R2): Review of the medical record revealed R2 was admitted to the facility 12/13/2024 with diagnoses that included kidney failure, acute cystitis (inflammation of the bladder), dissection of thoracic aorta, chronic ischemic heart disease, hyperkalemia (high potassium level), muscle weakness, anemia (low red blood count), post-traumatic stress disorder (PTSD), mood disorder, depression, and myalgia (muscle pain). [...]

Inspectors wroteThis citation pertains to intake MI00151282 Based on observation, interview, and record review the facility failed to provide food preferences for one Residents (#2) of three sampled Residents resulting in frustration and an unpleasant dining experience. Findings Included: Resident #2 (R2): Review of the medical record revealed R2 was admitted to the facility 12/13/2024 with diagnoses that included kidney failure, acute cystitis (inflammation of the bladder), dissection of thoracic aorta, chronic ischemic heart disease, hyperkalemia (high potassium level), muscle weakness, anemia (low red blood count), post-traumatic stress disorder (PTSD), mood disorder, depression, and myalgia (muscle pain). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/21/2025, revealed R2 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteThis citation pertains to intake #MI00150230 Based on observation, interview and record review, the facility failed to follow Physician's Orders for medications for one Residents (Resident #10) of 4 reviewed for physician orders.

Inspectors wroteThis citation pertain to intake: MI00149478, MI00149576, and MI00149772 Based on observation, interview, and record review the facility failed to follow acceptable professional guidelines, by using PDI Sani-Cloth Germicidal Disposable Wipes while performing incontinent bowel care for one resident (#101) out of three residents reviewed. Findings Included: Resident #101 (R101) Review of the medical record reviewed R101 was admitted to the facility 07/17/2020 with diagnoses that included traumatic brain injury, schizoaffective disorder, dementia, hypertension, speech and language deficits, Parkinson's disease, gastro-esophageal reflux, dysphagia (difficulty swallowing), muscle spasm, and dysarthria (slurred speech). [...]

Inspectors wroteThis citation pertains to Intake Numbers MI00148941, MI00148966 and MI00149186 Based on observation, interview and record review the facility failed to protect the resident's (R505) right to be free from sexual abuse by another resident (R501) of 7 sampled residents reviewed for abuse resulting in sexual assault of R505 who was cognitively impaired and also resulted in the likelihood of physical harm, infection, and emotional pain and suffering, based on the reasonable person concept. The Director of Nursing (DON) was interviewed on 12/18/2024 at 10:10 AM. and confirmed viewing the facility surveillance video captured on 12/12/24. The video taken on 12/12/24 at 7:42 PM showed R501 ushered R505 into R501's room. At 9:09 PM, R501 was seen on video looking up the hallway before ushering R505 back to her room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain plumbing and refrigeration equipment, resulting in the potential for an increased risk of foodborne illness, affecting all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to control pests in the kitchen and reduce harborage conditions, resulting in uncontrolled pests in the facility, affecting all residents in current facility census of 99 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Activities Director had minimum qualifications to perform the duties of the position effectively involving residents on the memory care unit with a current census of 20 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food at the preferred temperature for one resident (#57) and six residents (confidential resident group) and failed to provide condiments, food accuracy, preferred food palatability, preferred eating utensils, and preferred food items for six residents (confidential resident group) resulting in dissatisfaction during meals. Findings Included: Resident #57 (R57) Review of the medical record demonstrated that R57 was admitted [DATE] with diagnoses that included spinal stenosis, neoplasm (abnormal mass) related pain, malignant (cancer) neoplasm of the cervix, malignant neoplasm of bone, chronic obstructive pulmonary disease (CPOD), cognitive communication deficit, insomnia, mood disorder, depression, and back pain. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately report an injury of unknown origin for one out of six residents (Resident #25), resulting in the potential for further injuries of unknown origin to not be reported, and facility corrective action to not be taken. Findings Included: Per the facility face sheet R25 had been a resident at the facility since 11/16/2023 with a recent readmission on [DATE]. Review of an incident report dated 6/20/2024, revealed R25 was noted to have a small bruise that measured 0.5 inches by 0.5 inches on her forehead at her hairline. The report revealed R25 preferred to rest her head on the wall when standing in the bathroom while being changed. It was documented on the report, resident often leans forward and places head on wall. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a thorough investigation was conducted for one out of six residents (R25) sampled for alleged abuse resulting in the potential for abuse to occur, and necessary actions to not take place for resident protection. Findings Included: Per the facility face sheet R25 had been a resident at the facility since 11/16/2023 with a recent readmission on [DATE]. Review of an incident report dated 6/20/2024, revealed R25 was noted to have a small bruise that measured 0.5 inches by 0.5 inches on her forehead at her hairline. The report revealed R25 preferred to rest her head on the wall when standing in the bathroom while being changed. It was documented on the report, resident often leans forward and places head on wall. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete a comprehensive assessment for one (Resident #254) of twenty residents reviewed resulting in the potential for unmet care needs. Finding Included: Resident #254 (R254) Review of the medical record demonstrated R254 was admitted to the facility 06/10/2024 with diagnoses that included Parkinson's Disease, type 2 diabetes, chronic obstructive pulmonary disease (COPD), Epilepsy (disorder of the brain characterized by repeated seizures), schizoaffective disorder, atrial fibrillation, anxiety, insomnia, dementia, hypertension, depression, anemia (low red blood cells), orthostatic hypotension, and stroke. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement resident care plans in two of 20 residents reviewed for care plans, resulting in the likelihood for the development of pressure ulcers and injuries (Resident #34) and a delay in dental care (Resident #36). Findings Include: Resident #34 (R34): R34's Minimum Data Set (MDS), with assessment reference date of 3/22/24 revealed she was admitted to the facility on [DATE], and her cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The same MDS assessment revealed R34 was dependent in activities of daily living (ADL) care and, at the time of the assessment, had a facility acquired Stage 3 pressure ulcer (full tissue thickness loss; subcutaneous fat may be visible, but bone, tendon or muscle was not exposed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a meaningful, diverse, and engaging activity program for one resident (#44) of one resident reviewed for activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer Resident #34 with a mechanical lift, in one of four residents reviewed for accidents, resulting in a hematoma and bruises. Findings Include: Resident #34 (R34) On 6/27/24 at 8:35 AM R34 was observed lying in bed with her legs crossed at her knees. R34 had a raised bruise on the right side of her forehead. Resident Aide (RA) J and Certified Nurse Aide (CNA) I provided morning activities of daily living (ADL) care. Staff Development Registered Nurse (SDRN) C entered R34's room to perform a competency check-off for the mechanical lift transfer while surveyor was observing care. RA J placed a transfer sling with green binding under R34. RA J was guided by CNA I on how to don the sling and attach the sling to the mechanical lift transfer device (Maxi Lift). [...]

Inspectors wroteBased on observation, interview, and record review, the facility to ensure their medication error rate was below 5% when three medication errors were observed from a total of 27 opportunities for one resident (Resident #81) of seven reviewed resulting in a medication error rate of 11.11%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly schedule a dental referral, in one of one resident reviewed for dental care (Resident #36), resulting in continued pain and a delay meeting resident goals.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adaptive equipment for one resident (#30) out of twenty residents, resulting the potential for decrease independence with preparing meals and eating. Findings Included: Resident #30 (R30) Review of the medical record demonstrated R30 was admitted to the facility 04/30/2024 with diagnoses that included osteomyelitis (inflammation of bone caused by infection) of left ankle an foot, type 2 diabetes, arthritis, myocardial infarction (hear attack), heart disease, uropathy (disease affecting urinary flow), absence right leg below knee, urinary retention, cognitive communication deficit, depression, atherosclerosis (build-up of fats, cholesterol in and on the artery walls), peripheral vascular disease (PVD), hypertension, hyperlipemia (high fat content in blood), insomnia, and stroke. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper communication/documentation of Hospice services provided to one resident's responsible person (Resident #56) of one resident reviewed for Hospice services, resulting in a lack of coordination of comprehensive services and care provided. Findings Included: Resident #56 (R56) Review of the medical record demonstrated R56 was admitted to the facility 02/15/2024 with diagnoses that included dementia, traumatic subdural hemorrhage (brain bleed), type 2 diabetes, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), atrial fibrillation, urine retention, gastro-esophageal reflux, Alzheimer's Disease, depression, hyperlipidemia (high fat content blood), and hypertension. [...]

Inspectors wroteBased on interview and record review the facility failed to administer pneumococcal immunizations in accordance with the Center for Disease Control and Prevention (CDC) recommendations for one resident (#25) of five residents reviewed resulting in the potential for server illness and complications from pneumococcal disease Findings Included: Resident #25 (R25) Review of the medical record demonstrated that R25 was admitted to the facility 11/18/2023 with diagnoses that included dementia, chronic kidney disease, anxiety, hyperlipidemia (high fat content in blood), sever protein-calorie malnutrition, hypertension, depression, muscle weakness, insomnia, irritable bowel syndrome, and spinal stenosis. [...]

Inspectors wroteBased on interview, observation and record review the facility failed to honor residents rights for one resident #4 (R4) of one resident reviewed for resident rights resulting in increased anxiety, PTSD symptoms, decreased self-worth and psychosocial wellbeing. Findings Include; Resident #4 (R4) Review of the medical record revealed Resident #04 (R04) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, acute kidney failure, pressure ulcer of sacral region, malignant neoplasm of connective and soft tissue, major depression, anxiety, post-traumatic stress disorder, acquired absence of left hip joint, absence of left leg, segmental and somatic dysfunction of upper extremity and polyneuropathy. [...]

Inspectors wroteThis citation pertains to intake: MI00142444 Based on observation, interview, and record review the facility failed to obtain a timely urinary analysis for one resident (#7) of three residents reviewed for timely laboratory services. Findings Included: Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 05/24/2023 with diagnoses that included sepsis, bacterial infections, type 2 diabetes, chronic obstructive pulmonary disease (COPD), pressure ulcer sacral region, malignant neoplasm (cancer) of connective and soft tissue, depression, anxiety, adjustment disorder, post-traumatic stress disorder (PTSD), hypertension, and urinary tract infection. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/2023, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately record grievances for one resident (#1) out of three residents resulting in the potential for unresolved resident grievances. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 06/28/2023 with diagnoses that included infection following a surgical procedure, chronic obstructive pulmonary disease (COPD), asthma, ankylosis (abnormal stiffening and immobility of joints), right tibial (leg bone) tendinitis, adjustment disorder, anxiety, overactive bladder, chronic kidney disease, edema (swelling), ankle contracture (tissue tightening causing deformity), left tibial tendinitis, carpal tunnel syndrome of the left upper limb, and hypertension. [...]