Capital City Gardens Rehabilitation and Nursing Ce

In the surveyor’s words

From the most serious findings on record at Capital City Gardens Rehabilitation and Nursing Ce, in the surveyor’s own words.

• Immediate jeopardy, patternF600Oct 29, 2024

  Based on medical record review, facility staff interviews, review of the fire investigation report, observation of facility video camera footage, review of the facility submitted Self-Reported Incident (SRI), and review of facility policy, the facility failed to ensure a resident was free from neglect when staff did not timely implement fire procedures when a mattress/bedding fire occurred in Resident #19's room. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, negative health outcomes and/or death when on 09/26/24 at 11:46 P.M. […]

• Immediate jeopardy, patternF689Oct 29, 2024

  Based on medical record review, observations, facility staff interviews, resident interviews, family interviews, review of a fire drill report, review of emergency response reports, review of report of fire email communication, review of facility video camera footage, review of hospital records, review of the fire investigation report, and review of the facility policies for smoking and Oxygen Administration, the facility failed to ensure the residents environment remained as free from accident hazards as is possible when one resident (#19), who utilized oxygen therapy and who smoked cigarettes, possessed smoking materials, including cigarettes and a cigarette lighter, in her room. […]

• Immediate jeopardy, isolatedF678Mar 28, 2022

  THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of hospital continuity information, review of a staff statement, staff interviews, and review of facility policies for Cardio-Pulmonary Resuscitation (CPR) and Advance Directives, the facility failed to initiate CPR or contact Emergency Medical Services (EMS) for Resident #01 who was found unresponsive, without a pulse or respirations. Resident #01's medical record had no documented evidence of a current code status. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm when Resident #01 did not receive CPR and EMS was not contacted for assistance. […]

• Actual harm, isolatedF686Apr 24, 2023

  Based on observation, medical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure appropriate care and treatment to a resident with a new wound. Actual harm occurred to Resident #3 when Resident #3's wound was treated without a physician order, the physician was not notified of the new wound, the wound worsened into a stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed.) and currently an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar), and the open wound was exposed to possible infections when it was placed on an unsanitary pillow. […]

• Actual harm, isolatedF698Jun 22, 2022

  Based on medical record review, staff and family interviews, and review of the facility [CONDITION(S)] contract, the facility failed to ensure residents received hemodialysis as ordered/scheduled. Actual harm occurred on 06/04/22 when Resident #90 was not dialyzed as scheduled and was subsequently hospitalized in the intensive care unit (ICU) for fluid volume overload on 06/06/22. This affected one (Resident #90) out of three residents reviewed for [CONDITION(S)]. The facility identified three residents in the facility who received [CONDITION(S)]. The census was 86. Findings include: Review of Resident #90's medical record revealed an admitted [DATE]. Resident #90 was discharged to an acute care hospital on 06/06/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]