North Capitol Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at North Capitol Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 18, 2026

  Based on interview and record review, the facility failed to ensure adequate assistance and supervision was provided for a resident during incontinent care, resulting in a fall from bed and resident being hospitalized for a left hip fracture for 1 of 1 resident reviewed for falls (Resident B). Findings include: The clinical record for Resident B was reviewed on 8/12/26 at 12:56 p.m. The resident's diagnosis included, but were not limited to, cerebral palsy (lifelong neurological disorder that permanently affects movement, muscle control, and posture) and fracture of greater trochanter of left femur (broken left hip). A Quarterly Minimum Data Set (MDS) Assessment, completed 4/1/26, indicated the resident was cognitively intact. […]

• Actual harm, isolatedF689Jan 3, 2023

  Based on interview and record review, the facility failed to ensure a dependent resident did not experience a fall from their bed that later resulted in a hospitalization with a nasal fracture, lip hematoma (solid swelling of clotted blood within the tissues), and a clavicle contusion (bruise) for 1 of 1 resident reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/3/23 at 11:46 a.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, Alzheimer's disease with late onset, attention to tracheostomy, hemiplegia and hemiparesis, muscle weakness, contracture to left and right ankle, and malnutrition. […]

• Actual harm, isolatedF689May 11, 2022

  Based on interview and record review, the facility failed to provide a resident with adequate assistance of 2 staff members for bed mobility. This resulted in a fall with a [CONDITION(S)] for 1 of 3 residents reviewed for accidents (Resident B). Findings include: The clinical record for resident B was reviewed on 5/10/22 at 9:42 a.m. The Resident's diagnosis included, but were not limited to, fractured right hip and [CONDITION(S)] (inability to move one side of the body). A Physical Therapy Progress and Discharge Summary, dated 12/22/21, indicated he required total assistance rolling side to side in bed. He was dependent of the helper to do all the effort of turning. Assistance of 2 or more helpers was required for him to complete the activity. […]

• No harm, potential for more than minimal, widespreadF925Feb 8, 2022

  Based on observation, interview, and record review, the facility failed to implement recommended pest control interventions. This affected 54 of 54 residents in the facility. Findings include: A confidential interview was conducted with a staff member of the facility. They indicated they would find cockroaches physically on the residents, around their g-tubes (gastrostomy tubes) and near their [CONDITION(S)] tubes. It was really embarrassing when residents' family visited and found them on their family member. In the past year and half, it had been getting progressively worse. The 1/5/22 pest elimination service report was provided by the ED (Executive Director) on 2/7/22 at 1:05 p.m. It indicated a finding location of the first floor restroom behind the ED's office. […]

• No harm, potential for more than minimal, patternF602Jan 29, 2026

  Based 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)Findings include:1.An interview was conducted with the Director of Nursing Services (DNS) on 1/28/26 at 10:59 a.m. The DNS indicated there were about thirty fentanyl patches unaccounted for. At 3:30 p.m., the DNS indicated the Fentanyl/Duragesic Controlled Substance Record logs should have been completed by the nurse who removed the old fentanyl patch and applied the new fentanyl patch every 72 hours. It should have been the same nurse for removal as for new application, and a different nurse for the witnessed entries. […]