Capri Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Capri Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Aug 1, 2022

  Based on record review, review of facility's policy and procedure, staff, and resident interview the facility failed to implement a systemic approach to identify risk factors and implement appropriate interventions to prevent avoidable fall related serious injuries for 5 (Resident #20, #85, #193, #392, and #292) and 2 (Resident #27, and #192) with multiple falls, of 10 residents sampled with falls or fall related injuries. Resident #20 was admitted to the facility on [DATE] and was dependent on staff for repositioning. On 1/22/22 the resident rolled out of bed during care and sustained a nasal bone fracture. Resident #85 was admitted to the facility on [DATE] and was assessed to be at risk for falls. […]

• Immediate jeopardy, patternF835Aug 1, 2022

  Based on record review, staff, and resident interview the facility administration failed to use its resources effectively to ensure consistent and ongoing implementation of effective measures to prevent avoidable falls and fall related injuries. Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right [CONDITION(S)]. On 1/10/22 the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/22/22 Resident #20 sustained a nasal bone fracture when she was improperly turned in bed and fell . Resident #85 sustained multiple falls at the facility on 1/28/22, 2/5/22, 3/26/22, 3/30/22 and 5/14/22. On 2/5/22 Resident #85 was diagnosed with a left femoral neck, and left wrist fracture, left facial abrasion and contusion. […]

• Immediate jeopardy, patternF867Aug 1, 2022

  Based on record review and interview the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to prevention of avoidable falls and fall related serious injuries. On 1/22/22 Resident #20 sustained a nasal bone fracture when she was improperly turned in bed and fell . Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right hip fracture. On 1/10/22 the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85 sustained multiple falls at the facility on 1/28/22, 2/5/22, 3/26/22, 3/30/22 and 5/14/22. On 2/5/22 Resident #85 sustained a fall, was sent to the hospital and diagnosed with a left femoral neck fracture, left wrist fracture, left facial abrasion and contusion. […]

• Immediate jeopardy, isolatedF600Apr 7, 2023

  Based on review of the clinical record, review of facility policy and procedures and staff and family interviews, the facility failed to protect the resident's right to be free from neglect. The facility failed to provide the necessary services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. They failed to provide the correct diet and required assistance for one (Resident #43) of 3 sampled residents with dysphagia (difficulty swallowing). Resident #43 had a physician's order for a soft and bite sized diet, and required extensive assistance with meals. On [DATE] Resident #43 did not receive the necessary assistance during meals. Staff was not aware Resident #43 required extensive assistance with meals. […]

• Immediate jeopardy, isolatedF689Apr 7, 2023

  Based on record review, facility policy and procedures, and staff and family interviews, the facility failed to implement processes to communicate a change in condition and ensure adequate supervision and assistance to prevent the choking death for one (Resident #43) of 3 residents reviewed with dysphagia (difficulty swallowing). On [DATE] it was determined the findings of the survey posed Immediate Jeopardy to the health and safety of the residents in the facility. The Administrator was informed of the Immediate Jeopardy on [DATE] at 8:30 a.m. Immediate Jeopardy was identified on [DATE]. It began on [DATE] and was removed on [DATE]. The scope and severity was decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. […]