North Capitol Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to irrigate (flush) a urinary catheter, as ordered by the physician, for 1 of 3 residents reviewed for urinary catheters (Resident D).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to be free from misappropriation of their narcotic medication for 4 of 4 residents reviewed for misappropriation. (Residents C, D, E, and F)

Inspectors wroteF697Based on interview and record review, the facility failed to provide residents' pain medication, as ordered, and to verify placement of residents' fentanyl patches, as ordered, for 4 of 4 residents reviewed for pain management. (Residents C, D, E, and F)

Inspectors wroteBased on interview and record review, the facility failed to implement pharmaceutical procedures that assured the accurate acquiring, receiving, dispensing, and administering of narcotic medication; to ensure medication records were in order; and ensure that an account of all controlled medications was maintained and periodically reconciled for 4 of 4 residents reviewed for pain management. (Residents C, D, E, and F)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a staff member did not initiate chest compressions to a hospice resident that had an advanced directive in place Do Not Resuscitate (DNR) code status. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene during medication administration and failed to ensure that indwelling catheter tubing and drainage bag were kept off a fall mat and the floor for 6 of 8 residents reviewed for medication administration and 1 of 1 resident reviewed for urinary catheter. (Residents' 5, 12, 26, 34, 40, 50, and 72)

Inspectors wroteBased on observation and interview, the facility failed to ensure a call light system and ceilings and walls in residents' rooms were in good repair for 7 of 7 residents reviewed for environment, and to provide a home-like environment in the memory care unit common area with the potential to effect 19 of 19 residents. (Residents 1, 2, 15, 31, 34, 35, and E)

Inspectors wroteBased on interview and record review, the facility failed to timely coordinate care with hospice for scheduled pain medication and failed to administer medication as ordered for 1 of 1 resident reviewed for hospice and 1 of 5 residents reviewed for unnecessary medications. (Resident 11 and Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer gastric tube feeding as ordered by the physician for 1 of 1 resident reviewed for gastric tube feeding (Resident 5).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for a resident with intrusive wandering, document new behavior events in the clinical record, and timely update the plan of care with new interventions for behaviors for 2 of 3 residents reviewed for dementia care (Resident K and Resident 61).

Inspectors wroteBased on interview and record review, the facility failed to timely identify and obtain physician's orders for a surgical wound that was present upon admission to the facility for 1 of 4 residents reviewed for wounds (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who required follow-up care with an Ears, Nose, and Throat (ENT) physician was provided transportation to those appointments 1 of 3 residents reviewed for quality of care. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's safety when using a mechanical sling lift by a staff member not securing the sling clip to the peg on the mechanical lift and causing a resident to fall to the floor for 1 of 3 residents reviewed for falls. (Resident K)

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store foods in the kitchen. This affected of 60 residents in the facility who eat food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean, comfortable, homelike environment related to splintered chair rails behind beds; scrapped walls with exposed drywall; phone [NAME] with exposed wires; not ensuring wheel chairs were clean; not assuring feeding pump poles were clean; bed linens, towels, and washcloths with stains; bedroom furniture on the vent unit with missing and scratched veneer; and floors with loose and missing tiles for 10 of 15 residents reviewed for environment (Resident D, 21, 24, 27, 28, 30, 36, 44, 53 and 55).

Inspectors wroteBased on observation, interview and record review, the facility failed to have the Interdisciplinary team (IDT) determine and document a self medication assessment was clinically appropriate for 1 of 1 residents randomly observed with medications by their side in a common area. (Resident 18)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dependent residents with oral care, complete bed bath, hair care, and emptying of a bedside commode for 3 of 6 residents reviewed for activities of daily living (ADLs). (Resident D, Resident E, and Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a low air loss mattress was functioning for 2 of 2 residents reviewed for pressure ulcers. (Resident D and Resident 45)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure flooring was in good condition to prevent accident hazards for a resident that had tripped on loose flooring and had fallen for 1 of 2 residents reviewed for accidents. (Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during incontinence care and ensure follow-up regarding changes in urinary output from an indwelling urinary catheter for 1 of 2 residents reviewed for urinary catheter. (Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident with a tracheostomy (trach) after providing trach care for 1 of 1 residents reviewed for death; ensure infection control practices were maintained during tracheostomy care (Resident D), and oxygen tubing/tracheostomy mask were changed as ordered (Resident E) for 2 of 3 residents reviewed for respiratory care. (Resident 60)

Inspectors wroteBased on interview and record review, the facility failed to timely obtain laboratory tests, as ordered by the physician, for 1 of 5 residents reviewed for unnecessary medications (Resident 5).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during medication administration, while providing a bed bath (Resident F), and ensure personal protective equipment (PPE) was available to utilize prior to entering a room on transmission-based precautions (TBP) (Residents' 6, 21, 22, 41 and 56).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy curtains were present rooms shared by two resident for 4 of 15 residents reviewed for environment (Resident 14, 36, 43, and 53).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functional and sanitary environment by not assuring the resident rooms were routinely dusted for 3 of 3 residents observed for environment (Resident 54, 56, and 66), and that the kitchen floor was in good repair with the potential to affect 60 of 69 residents who reside at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was invited to participate in interdisciplinary care plan meetings for 1 of 1 resident reviewed for care planning (Resident 38).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities provided in the memory care unit was engaging to a cognitive impaired resident for 1 of 1 residents reviewed for activities in the memory care unit. (Resident G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident's supplement, as ordered, to 1 of 1 resident reviewed for nutrition (Resident 61) and to administer medications as ordered for 1 of 6 residents reviewed for unnecessary medications. (Resident G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that hand hygiene was performed prior to donning sterile gloves and performing tracheostomy care of 1 of 1 resident reviewed for tracheostomy care (Resident 28).

Inspectors wroteBased on interview and record review, the facility failed to assess a resident's pain that included location of the pain, intensity of the pain and effectiveness of an as needed (PRN) pain medication, and provide non-pharmacological interventions to address the resident's pain for 1 of 2 residents reviewed for accidents. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had adequate indication for use of an antibiotic, did not receive duplicate antibiotic therapy (Resident 58 and 31), and to monitor a resident's medication by not timely obtaining a VPA (valproic acid) lab, as ordered, (Resident 47) for 3 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program which contains protocols to ensure residents who require antibiotics are prescribed the appropriate antibiotic, monitors/re-evaluates the use of antibiotics, provides appropriate indications for use, and failure to adhere to an algorithm for identification of a true infection for 2 of 5 residents reviewed for unnecessary medications. (Residents 58 and 31)

Inspectors wroteBased on interview and record review, the facility failed to timely administer a resident's influenza vaccination for 1 of 5 residents reviewed for vaccination. (Resident 56)