Capitol City Rehab and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Capitol City Rehab and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF760Mar 10, 2023

  Based on review of a facility reported incident, medical records, facility documentation, and interviews with family members and staff, for four (4) of 101 sampled residents, the facility's staff failed to 1. safely administer medications in accordance with Standard of Practice or Manufactures Specifications as evidenced by (1) Employee #22 (Agency Registered Nurse; RN) administered one unit of Novolog R insulin to Resident #313 without a physician's order on [DATE], (2) Employee # 25 (Agency RN) signed that he administered medication to Resident #494 who had no medication in the facility, (3) Employee #11 (RN) administered Resident #5 a deceased resident's (Resident #488) medication (Gabapentin), and (4) storing and administering expired Humalog (Lispro) insulin medication to Resident #… […]

• Immediate jeopardy, patternF761Mar 10, 2023

  Based on review of a facility reported incident, medical records, facility documentation, and family and staff interviews, for six (6) of 104 sampled residents, the facility's staff failed properly store medications in accordance with Standards of Practice or Medication Manufacturer's Specifications as evidenced by: (1) not ensuring Resident #7's individual medication compartment did not contain expired Humalog (Lispro) insulin. Subsequently, the resident was administered expired Humalog (Lispro) insulin, (2) Employee #34 failed to ensure Resident #224's individual medication compartment did not contain a deceased resident's [Resident #488] medication, Subsequently the resident was administered the deceased resident's medication [Gabapentin], (3) Employee #35 stored Resident #147's Novolog… […]

• Immediate jeopardy, isolatedF600Jun 20, 2024

  Based on observations, record reviews, staff interviews and a resident's interview, for three (3) of nine (9) sampled residents, the facility failed to ensure residents were free from physical abuse as evidenced by: (1) The Administrative staff making the decision to place Resident #2 (new admission), who was known for physical aggressive behaviors toward other residents, in a room with Resident #1, who was also known for physical aggression against other residents and staff and sexual misconduct. […]

• Immediate jeopardy, isolatedF689May 6, 2024

  Based on observations, record reviews, resident and staff interviews, for five (5) of 16 sampled residents, the facility's staff failed to: (1) implement safety measures to prevent Resident #1 from having access to a lighter. As a result, Resident #1 lit Resident #2's bedsheets and mattress on fire with the lighter at approximately 11:25 PM on 04/20/24. (2) Ensure Resident #8's safety by providing adequate supervision to prevent her from wandering into other residents' rooms, resulting in Resident #8 sustaining a head laceration when Resident #6 hit her in the head with a cane for wandering into his room on 02/08/24. (3) Ensure Resident #6 was adequately supervised while possessing a cane following an incident where he used it as a weapon on 02/08/24. […]

• Immediate jeopardy, isolatedF610Aug 25, 2023

  Based on record review and staff interviews, for two (2) of 12 sampled residents, facility staff failed to implement corrective actions to prevent further potential abuse or mistreatment of Resident #12 while the investigation is in progress and failed to conduct a thorough investigation of Resident #2's allegation of employee abuse. Residents' #12 and #2. The findings included: Review of the facility policy Abuse, Neglect and Exploitation last reviewed on 05/19/23 documented, .Investigations of alleged abuse .include . identifying and interviewing all involved persons, including . […]