Cadia Rehabilitation Capitol

In the surveyor’s words

From the most serious findings on record at Cadia Rehabilitation Capitol, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jan 27, 2026

  Based on interview and record review, it was determined that for one (R5) out of nine residents reviewed for medication administration, the facility failed to ensure that R5 received the correct dose of morphine sulfate for pain when R5 erroneously received 15 mL (milliliter) of the concentrated morphine sulfate oral solution instead of the physician prescribed dose of 0.25 mL on 12/7/25 at 10:58 AM. With this significant medication error, R5 was at risk of a severe, life-threatening respiratory depression or death. R5 was administered Naloxone 0.4 mg/mL intramuscularly two times to reverse R5's overdosage on 12/7/25 at 4:13 PM and 8:02 PM. An immediate Jeopardy (IJ) was identified starting 12/7/25. […]

• Actual harm, isolatedF689Jul 16, 2024

  Based on interview, record review and review of other facility documentation it was determined that for one (R1) out of three residents reviewed for accidents the facility failed to provide adequate supervision to prevent an accident. R1, a totally dependent resident was rolled out of bed when a staff person lost grip on R1 during care. R1 rolled from the bed and fell three (3) feet to the floor sustaining a laceration to the head and was emergently transported to the hospital, this resulted in harm to R1. 6/6/17 - R1 was admitted to the facility with diagnoses of but not limited to unspecified dementia (a brain disorder with memory loss), sarcoidosis (an inflammatory disease) and aphasia (neurological condition affecting language). […]

• No harm, potential for more than minimal, widespreadF812Dec 12, 2024

  Based on observation, interview, and facility policy review, the facility failed to ensure that beard guards were worn during food production in accordance with professional standards for food service safety and failed to store food in accordance with professional standards for service safety with the potential to affect 109 of 109 residents who consumed food from the kitchen. This failure had the potential for physical contamination of the food in the facility. Findings include: 1. Review of the facility's policy titled, Dress Code dated [DATE], revealed sanitary food preparation staff must wear: hair net or a disposable hat while on duty. Any employee with facial hair must wear a beard guard. […]

• No harm, potential for more than minimal, patternF641Nov 8, 2023

  Based on record review and interview, it was determined that for two (R98 and R417) out of twenty-nine residents reviewed for resident assessment, the facility failed to accurately complete MDS assessments to reflect resident status. Findings include: 1. Review of R98's clinical record revealed: 5/9/23 - R98 was readmitted to the facility with dementia. 5/10/23 1:00 AM - A provider progress note documented that R98 was, referred from home to Cadia for LTC (long term care) due to progressive dementia. 5/11/23 - R98's care plan included that R98 had impaired cognitive function or impaired thought process related to dementia. 5/17/23 - R98's admission MDS assessment did not include R98's diagnosis of dementia. […]

• No harm, potential for more than minimal, patternF644Nov 8, 2023

  Based on interview and record review, it was determined that for four (R30, R38, R40 and R74) out of five residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed following a new diagnosis of psychotic disorder which was not listed on the previous PASARR. Findings include: 1. Review of R30's clinical record revealed: 3/7/18 - R30 was admitted to the facility. 3/6/18 - A review of R30's medical record revealed that R30 had a PASARR level I that indicated R30 had a documented serious mental illness (mood disorder with depressive features) and demonstrated a full level II was not indicated at that time. […]