Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Capitol Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to irrigate a resident’s urinary catheter as ordered. The resident had obstructive and reflux uropathy with an indwelling catheter, and the care plan called for assistance with catheter care and avoiding obstruction. The resident reported the catheter kept clogging and staff did not help with catheter care; cloudy urine with sediment was observed in the tubing. An LPN said the ordered Clorpactin was not available on the unit, and the DON said it had not been in the building and nurses may have used NS instead.
Surveyors found that the facility failed to protect residents from misappropriation of fentanyl patches and did not maintain accurate controlled substance documentation. Multiple residents had orders for 72‑hour fentanyl patches, with MARs showing regular application primarily by an RN and an LPN, but corresponding controlled substance logs were missing for extended periods and, when present, conflicted with MAR entries. Logs frequently lacked required witnesses for patch removals, omitted documentation of removals when new patches were applied, and showed the same RN signing as both administering nurse and witness. Pharmacy records showed that numerous fentanyl patches delivered for several residents were unaccounted for, and a hospice nurse reported that no fentanyl patches were available for a resident despite a recent delivery. The DNS acknowledged that narcotic logs were not routinely reviewed for accuracy and that shift‑change controlled substance verification forms were missing or undated, contrary to facility policy requiring complete storage, documentation, inventory, and accounting of controlled substances.
Surveyors found that the facility did not consistently administer ordered fentanyl patches or verify their placement every shift for four residents with chronic pain or neuralgia. For several residents who were non-verbal or rarely understood and showed non-verbal signs of pain, care plans and MD orders required 72-hour fentanyl patches every three days and every-shift verification. MARs showed missed patch applications attributed to unavailable medication or need for a new prescription, as well as multiple shifts with no documented verification of patch placement. The DON reported issues involving two nurses and fentanyl patch diversion on the affected unit.
A facility failed to ensure accurate acquisition, administration, and accounting of fentanyl patches for four residents with chronic pain or neuralgia. Physician orders and MARs showed regular application of 72‑hour fentanyl patches, primarily by an RN and an LPN, but controlled substance logs were missing for extended periods and, when present, often contradicted the MARs on application dates. Numerous patch removals lacked a witness, some new patch applications had no corresponding removal documented, and the RN frequently signed as her own witness. Pharmacy records showed multiple fentanyl patches delivered for each resident with several unaccounted for. The DNS reported that required shift‑to‑shift controlled substance counts, proper witnessing, and scanning of controlled substance records into resident documents were not consistently performed, and narcotic logs were not routinely reviewed for accuracy unless a discrepancy was reported.
A resident with Alzheimer's disease, under hospice care and with a documented DNR order, experienced a fall with seizure activity and head injury. Despite the DNR status, an LPN initiated chest compressions after being instructed by a 911 dispatcher, even though the resident had a heartbeat and was breathing. The advanced directive was present in the resident's record, and the resident's representative was upset that CPR was performed.
Hand hygiene was not observed during several medication administrations by an LPN, who touched her hair, eyeglasses, cart items, medication cards, cups, and other surfaces before giving meds to residents with diagnoses including schizophrenia, stroke, Parkinson's disease, and hypertension. In another observation, an RN prepared meds for a resident with a G-tube and donned PPE without hand hygiene first. The facility also failed to keep a resident's indwelling catheter tubing and drainage bag off a fall mat and the floor, despite the care plan directing that the drainage system not touch the floor.
The facility failed to keep resident rooms in good repair and maintain a safe call light system. Multiple rooms had gouges, missing paint, broken or missing baseboards, holes, ceiling splatter, and one room had exposed wiring from a call light cord. A resident said the wall damage had been present for about a year. The memory care common area was also plain, with tables pushed to the center and no decorations or personalization, and the ED stated the area could use more personalization and that no policy existed for home-like environment standards.
A resident on hospice with dementia and arthritis did not have a tramadol order entered into the EHR even though hospice had intended for the medication to be given twice daily for pain, and the HN was unaware the resident was not receiving it as intended. Another resident with a stroke diagnosis missed ordered metoprolol doses on multiple days, with some doses held for low BP and others lacking documentation, and the record did not show provider notification for the holds.
G-tube feeding was not administered as ordered for a resident with epilepsy and g-tube status. The resident's enteral nutrition was observed running at 55 mL/hr with 40 mL water flushes/hr, even though the MD order specified 50 mL/hr with 45 mL water flushes/hr. An RN reviewed the order and confirmed the mismatch with the prescribed rate and flushes.
Failure to document and care-plan intrusive wandering and resident-to-resident behaviors: A resident with dementia, behavioral disturbances, and daily wandering repeatedly entered other residents’ rooms, required redirection, and was involved in resident-to-resident incidents with another resident who also had dementia with psychotic disturbance. The record lacked required behavior documentation and IDT review for the new/high-risk behavior, and the care plan was not timely updated to reflect the incidents and interventions.
A resident was admitted with a surgical wound on the right buttock and a dehisced abdominal wound, but the facility failed to obtain timely treatment orders. The abdominal wound was mistakenly treated as a second ostomy, leading to inadequate care. The oversight was acknowledged by staff, and the resident was eventually transferred to a hospital when the wound condition worsened.
A resident with complex medical needs missed several critical medical appointments due to the facility's failure to arrange transportation and ensure accompaniment by a respiratory therapist. The facility's policies for scheduling and documenting appointments were not followed, resulting in a deficiency in care.
A resident with cerebral palsy and muscular dystrophy fell during a transfer using a mechanical sling lift when a CNA failed to secure the sling clip properly. The resident sustained injuries and was taken to the emergency room. The CNA reported previous issues with the clip not locking and was retrained after the incident.
The facility failed to properly store and label food in the kitchen, affecting 60 residents. Observations included unlabeled thawing meat, expired lactose-free milk, milk stored on the fridge floor, and unlabeled pre-poured drinks. The Dietary Manager's mustache was uncovered, and a trash can lacked a lid. These actions violated the facility's Food Storage policy and sanitation requirements.
The facility failed to maintain a clean and homelike environment, with issues such as splintered chair rails, exposed drywall, and stained linens observed in several residents' rooms. Equipment like wheelchairs and feeding pump poles were unclean, and housekeeping practices were inadequate, as noted by an RN. The executive director acknowledged ongoing problems, and interviews with residents and family members highlighted complaints about stained linens and worn furniture.
A resident was found with a medication cup containing unidentified pills in a common area, expressing concern about the medications and refusing to take them. The LPN believed the resident had taken the medications, but the resident denied this. The resident's clinical record lacked a Self-Administration of Medication assessment, despite her diagnoses and moderate cognitive deficit. The facility's policy requires an assessment by the IDT, which was not conducted.
Two residents with pressure ulcers were found with non-functioning low air loss (LAL) mattresses due to improper connections. Resident D, with multiple health issues, was observed over two days with a non-operational mattress until a respiratory therapist corrected the plug connection. Similarly, Resident 45, with a history of pressure injuries, had a disconnected pump that was fixed by the therapist. The facility's policy required functioning pressure redistribution mattresses, which was not followed.
A resident with multiple health conditions, including chronic respiratory failure and muscle weakness, fell after tripping on loose flooring while transferring from a wheelchair to a bed. The bed was not locked, contributing to the fall. The facility's policy on fall management was not effectively implemented, as the flooring issue was known but not addressed in time to prevent the accident.
A facility failed to maintain infection control during incontinence care and did not follow up on changes in urinary output for a resident with an indwelling catheter. The resident, with multiple health issues, was observed receiving improper perineal care and had a catheter bag positioned incorrectly. Subsequent observations showed sediment in the catheter tubing and bag, but the facility did not communicate these changes as per their policy.
The facility failed to provide adequate respiratory care for residents with tracheostomies, as evidenced by improper infection control practices during trach care for a resident, failure to change oxygen tubing as ordered for another resident, and lack of comprehensive documentation following a trach removal incident for a third resident.
A resident with multiple health conditions did not have scheduled laboratory tests obtained as ordered by the physician. The facility's guidelines for lab tracking were not followed, resulting in missing lab results. Interviews revealed a lack of awareness and record of the lab orders, contributing to the deficiency.
The facility failed to maintain infection control practices during a bed bath for a resident and medication administration for multiple residents. A CNA used the same gloves and washcloth for different body areas without changing gloves, and an LPN placed fingers inside medication cups and pill crusher sleeves without performing hand hygiene. Additionally, PPE was not available outside the room of a resident on transmission-based precautions, leading staff to enter without proper PPE.
The facility failed to provide privacy curtains in shared rooms, affecting four residents. A cognitively intact resident and another resident shared a room without a privacy curtain between their beds. Another resident with an anoxic brain injury and a resident with moderately impaired cognition due to diabetes shared a room lacking a privacy curtain on one side of the bed. The Executive Director confirmed that privacy curtains should be present.
The facility failed to provide adequate care for three residents, including oral hygiene, complete bed baths, hair care, and emptying of bedside commodes. A resident with multiple health issues was observed with a coated tongue despite orders for oral care. Another resident's bedside commode was not emptied for hours, and a third resident received an incomplete bed bath, with greasy hair observed over several days. These deficiencies highlight neglect in providing necessary assistance with ADLs.
Failure to Irrigate Urinary Catheter as Ordered
Penalty
Summary
The facility failed to irrigate a urinary catheter as ordered for one resident with obstructive and reflux uropathy and an indwelling urinary catheter. The resident’s care plan, last reviewed on 3/11/26, indicated the catheter was related to obstructive uropathy and included interventions to avoid obstruction in catheter drainage and provide assistance with catheter care. A quarterly MDS assessment completed on 3/18/26 identified the resident as cognitively intact and having an indwelling urinary catheter. A physician order dated 4/24/26 directed that Clorpactin WCS-90, 60 ml, be instilled into the bladder through the indwelling catheter, remain in the bladder for 15 to 30 minutes, and then be drained every three days. The April and May 2026 MARs showed the medication was unavailable from pharmacy on 4/27/26 and marked completed on 4/30, 5/3, and 5/6/26. During interview, the resident stated the catheter kept getting clogged, staff did not assist with catheter care, and the catheter had not been irrigated at the facility; cloudy urine with sediment was observed in the tubing. An LPN stated the Clorpactin was not in the unit treatment cart or medication room and had never been sent by pharmacy, and the DON stated it had not been in the building and that nurses may have irrigated with normal saline instead of the ordered Clorpactin.
Misappropriation and Poor Accountability of Fentanyl Patches
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their narcotic medications, specifically fentanyl patches, and to ensure accurate storage, documentation, and accounting of these controlled substances. The DNS reported that approximately thirty fentanyl patches were unaccounted for and that multiple Fentanyl/Duragesic Controlled Substance Record logs were missing. The DNS stated that narcotic logs were not routinely reviewed for accuracy or completeness and were only examined when staff reported a discrepancy. She also noted that the logs that were available contained entries that did not make sense, such as an LPN documented as witnessing an RN’s fentanyl patch application despite the two not working the same shift. For Residents C, D, E, and F, physician orders required application of 72‑hour fentanyl patches every three days, and MARs for July, August, and September documented regular application of these patches, almost exclusively by one RN and one LPN. However, for each of these residents, there were no corresponding controlled substance logs for significant time periods, and the available logs contradicted the MARs. For Resident F, there were no fentanyl logs from early July to mid‑August, and the later logs showed application dates that did not match the MARs, lacked required witnesses for removals, documented instances where no removal was recorded when a new patch was applied, and showed the RN acting as her own witness on multiple dates. Pharmacy delivery records indicated that 49 patches were delivered for Resident F, with 13 unaccounted for. A hospice clinical director reported that when hospice requested a fentanyl patch change for this resident, no patches were available despite a recent delivery. Resident C’s MARs showed regular fentanyl patch application every three days, but there were no controlled substance logs from early July to mid‑August, and the existing logs for mid‑August through late September conflicted with the MARs. The logs showed missing witnesses for multiple removals, missing documentation of removals when new patches were applied, and the RN serving as her own witness on several dates. Pharmacy records showed 31 patches delivered for Resident C, with 4 unaccounted for. Resident E’s MARs also documented regular fentanyl patch application, with almost all applications by the same RN and LPN, but there were no logs for early July to mid‑August, and the later logs again conflicted with the MARs, showed missing witnesses, missing removals when new patches were applied, duplicate entries for the same date and time, and the RN acting as her own witness. Pharmacy records showed 40 patches delivered for Resident E, with 14 unaccounted for. Resident D had orders for a 72‑hour fentanyl patch with shift‑by‑shift verification of placement. MARs documented regular application every three days, primarily by the same RN and LPN, but there were no controlled substance logs for early July to mid‑August or for mid‑September to late September. The available logs for mid‑August to late September conflicted with the MARs, showed application dates that did not align with the MARs, lacked witnesses for multiple removals, omitted documentation of removals when new patches were applied, and again showed the RN serving as her own witness on several dates. Pharmacy documentation indicated that 40 fentanyl patches were associated with Resident D, with 19 unaccounted for. Interviews documented in the investigative file showed that the RN acknowledged applying patches, and the LPN reported being allergic to fentanyl and stated that the RN applied the patches; the LPN also reported taking Percocet and had a positive urine drug screen for opioids during the investigation. The facility’s own policies required that controlled substances be stored, recorded, accounted for, and documented on both the MAR and the resident’s controlled substance record, with shift‑to‑shift counts and maintenance of verification forms, and defined misappropriation as wrongful use of a resident’s property or money without consent. The DNS acknowledged that she was unsure whether the pharmacist routinely reviewed narcotic logs and that one month’s shift‑change controlled substance verification form was missing while another was undated and could not be definitively tied to a specific month. The facility’s investigation, based on pharmacy delivery records, physician orders, MARs, and the limited available controlled substance logs, concluded that there were unaccounted‑for fentanyl patches for all four residents, calculated as the difference between the number of patches delivered, the number ordered to be administered, and the number remaining. The survey findings also cross‑referenced failures to verify placement of fentanyl patches as ordered and failures to implement pharmaceutical procedures that assured accurate acquiring, receiving, dispensing, and administering of narcotic medications.
Failure to Administer and Verify Ordered Fentanyl Patches for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered fentanyl transdermal patches and to verify their placement every shift for four residents with chronic pain or neuralgia. For one resident with chronic pain who was non-verbal and required staff to anticipate her needs, the care plan directed staff to administer medications as ordered and to verify fentanyl patch placement every shift. Physician orders required application of a 72-hour fentanyl patch every three days and verification of patch placement each shift. The MAR showed the patch was not applied on one date because the medication was unavailable, and multiple shifts in July, August, and September did not have documented verification of patch placement as ordered. Another resident with chronic pain, who could not reliably participate in a pain interview and exhibited daily non-verbal indicators of pain, had orders for a 72-hour fentanyl patch every three days and for every-shift verification of patch placement. The MAR showed a gap between patch applications, missing two ordered applications, with one missed application documented as due to medication unavailability, and missing verification entries on specified shifts. A third resident with chronic pain had an order for a 72-hour fentanyl patch every three days and every-shift verification; the MAR documented a missed application due to the need for a new prescription and missing verification entries on two first shifts. A fourth resident with neuralgia had long-standing orders for a 72-hour fentanyl patch every three days and every-shift verification; the MAR showed at least one shift where verification of patch placement was not documented. The DNS reported there had been issues involving two nurses and fentanyl patch diversion on the unit where these residents resided.
Unaccounted Fentanyl Patches and Inaccurate Controlled Substance Documentation
Penalty
Summary
The deficiency involves the facility’s failure to implement pharmaceutical procedures that ensured accurate acquiring, receiving, dispensing, administering, and accounting of fentanyl patches for four residents with chronic pain or neuralgia. For Resident F, who had chronic pain and was newly admitted to hospice, the hospice nurse discovered that a fentanyl patch due for application was unavailable despite a recent delivery. Physician orders required a 72‑hour 25 mcg/hr fentanyl patch every three days over several periods in 2025. The MARs for July, August, and September documented regular patch applications on specific dates, almost exclusively by two nurses (an RN and an LPN). However, there were no corresponding controlled substance record logs for early July through mid‑August, and the available logs from mid‑August to late September contradicted the MARs regarding application dates. The logs also showed missing witness signatures for multiple patch removals, instances where no removal was documented when a new patch was applied, and entries where the RN signed as her own witness. Pharmacy records showed that 49 patches were delivered for this resident during the review period, with 13 unaccounted for. For Resident C, who also had chronic pain and nonverbal indicators of pain such as grimacing and facial expressions, physician orders required a 72‑hour 75 mcg/hr fentanyl patch every three days. The MARs for July through September showed patches applied as ordered, except for one date when the medication was unavailable, again almost exclusively by the same RN and LPN. There were no fentanyl controlled substance logs for early July through mid‑August. The logs from mid‑August to late September conflicted with the MARs on application dates and showed multiple patch removals without a witness, missing documentation of patch removals when new patches were applied, and instances where the RN signed as her own witness. Pharmacy documentation indicated that 31 patches were delivered for this resident in the review period, with 4 unaccounted for. The DNS later produced only one undated shift‑change controlled substance verification form for either August or September and confirmed that the other month’s form was missing. Resident E, with chronic pain and an order for a 72‑hour 25 mcg/hr fentanyl patch every three days, had MARs documenting regular patch applications in July, August, and September, almost all by the same RN and LPN. There were no controlled substance logs for early July through mid‑August. The logs from mid‑August to late September contradicted the MARs on application dates and showed multiple undocumented or unwitnessed patch removals, including several dates where new patches were applied without any recorded removal. One date showed two separate entries for patch application at the same time, and the RN again signed as her own witness on multiple occasions. Pharmacy records showed 40 patches delivered for this resident, with 14 unaccounted for. Resident D, diagnosed with neuralgia and ordered a 72‑hour 50 mcg/hr fentanyl patch every three days with shift‑by‑shift verification of patch placement, had MARs indicating regular patch applications in July, August, and September, primarily by the same RN and LPN. There were no controlled substance logs for early July through mid‑August or for mid‑September through late September. The available logs from mid‑August to late September conflicted with the MARs on application dates and showed multiple patch removals without a witness, missing documentation of removals when new patches were applied, and several entries where the RN signed as her own witness, including dates with duplicate entries. Pharmacy documentation indicated that 40 patches were administered or delivered for this resident, with 19 unaccounted for. The DNS stated that the facility’s policy required the nurse who removed the old fentanyl patch and applied the new one every 72 hours to complete the controlled substance record, with the same nurse documenting both removal and application and a different nurse serving as witness. She acknowledged that the logs did not make sense, including instances where the LPN was documented as witnessing the RN’s application despite not working the same shift. She also stated that completed logs were supposed to be filed and uploaded into the residents’ electronic records, but multiple logs were missing, particularly for Resident D’s recent deliveries. The DNS reported that no one at the facility routinely reviewed narcotic logs for accuracy or to ensure all narcotic medications were accounted for; she only reviewed them when staff reported discrepancies. The facility’s written policy on controlled substances required that administration be documented both on the MAR and on the resident’s controlled substance inventory record at the time of administration, and that shift‑change verification forms and addition/removal logs be maintained for 24 months and scanned into resident documents, but these procedures were not consistently followed for the four residents.
Failure to Honor DNR Order During Emergency Response
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's Do Not Resuscitate (DNR) advanced directive. The resident, who had Alzheimer's disease and was receiving hospice services, had a clearly documented DNR status in the clinical record, care plan, and physician orders. Despite this, after the resident experienced an unwitnessed fall resulting in a head laceration and seizure activity, a Licensed Practical Nurse (LPN) initiated chest compressions on the resident. The LPN, upon finding the resident on the floor with seizure activity and snoring respirations, checked the code status and then called 911. While on the phone with the dispatcher, the LPN was instructed to begin CPR and performed light chest compressions, even though the resident had a heartbeat and was still breathing. The resident subsequently came out of the seizure, and her breathing returned to normal before EMS arrived and transported her to the hospital for evaluation. Interviews with facility staff and the resident's representative confirmed that the advanced directive was known and accessible in the resident's chart. The resident's representative expressed distress that CPR was initiated despite the DNR order. The facility's policy stated that care should reflect the resident's wishes as expressed in the advanced directive, but this was not followed during the incident.
Hand Hygiene Not Performed During Medication Passes and Catheter Drainage System Left on Floor
Penalty
Summary
The facility failed to perform hand hygiene during medication administration for multiple residents. During observations of medication passes for residents with diagnoses including paranoid schizophrenia, stroke, Parkinson's disease, and hypertension, an LPN was seen touching her hair, eyeglasses, computer mouse, keys, medication cards, medication cups, water pitcher, and drinking cups while preparing medications, but hand hygiene was not observed before or after administering medications. In one observation, the LPN donned gloves in a resident's room, touched the bedside table with gloved hands, administered nasal spray, doffed the gloves, and then handled a straw for the resident without observed hand hygiene before or after glove use or before medication administration. A separate medication administration observation involving an RN showed hand hygiene was performed before arriving at the medication cart, but after using a laptop to verify orders and preparing crushed and liquid medications for a resident with a gastrostomy tube, the RN entered the room and donned a gown and gloves without performing hand hygiene first. The RN then verified gastrostomy tube placement and administered the medications. During interview, the RN stated she normally used hand hygiene before donning PPE and administering medication, but must have forgotten during the observation. The DON stated the LPN should have utilized hand hygiene prior to medication administration. The facility also failed to keep indwelling catheter tubing and drainage equipment off the floor for a resident with epilepsy, gastrostomy status, and an indwelling urinary catheter for neurogenic bladder. The care plan directed staff not to allow catheter tubing or any part of the drainage system to touch the floor and to position the drainage bag below the bladder. However, observations showed the catheter tubing laying on a fall mat beside the bed, and later the tubing remained on the fall mat while the drainage bag was behind the fall mat and touching the floor. RN 3 stated the catheter tubing should not be on the fall mat and the drainage bag should not be touching the floor.
Unsafe Room Conditions and Non-Home-Like Memory Care Common Area
Penalty
Summary
The facility failed to ensure resident rooms were kept in good repair and that the call light system was safe and intact. During observations, multiple resident rooms had gouges, scrapes, missing paint, missing or broken baseboards, cracks, holes in walls, and splatter of unknown origin on ceilings. In one room, exposed wiring from a call light cord was observed coming out of the wall with the cover detached. One resident stated the wall damage had been present for about a year and said he wanted it fixed. During the environmental tour, the Executive Director and Maintenance Director acknowledged the damaged walls and baseboards, and the Maintenance Director stated the damage was from residents' wheelchairs and that the wall had been previously repaired. The facility also failed to provide a home-like environment in the memory care unit common area. The third-floor common area was observed with multiple tables pushed to the center of the room and plain walls with no decorations or personalization. The Executive Director stated the area appeared plain and could use more personalization to provide a more home-like environment. He also stated the facility did not have a policy related to home-like environment standards.
Failure to Coordinate Hospice Pain Medication and Administer Ordered Medication
Penalty
Summary
The facility failed to coordinate hospice care for Resident 11, who had diagnoses including senile degeneration of the brain and generalized arthritis and was on hospice for comfort-focused care. The care plan directed staff to administer pain medications as ordered and notify the physician and hospice of unrelieved or worsening pain. A hospice IDG update indicated tramadol 25 mg twice daily for pain, but the electronic health record did not contain a physician order for that medication. The hospice nurse stated she had given the order to start tramadol 25 mg twice daily on 5/22/25, but could not recall which facility nurse received it, and she was unaware the resident had not been receiving it twice daily. The DON stated the facility did not have the order in the EHR and was unsure why it had not been entered. The facility also failed to administer metoprolol as ordered for Resident D, who had a diagnosis of stroke and an order for metoprolol 100 mg once daily. The July 2025 MAR showed the medication was not given on multiple days, including two instances documented as held for low blood pressure, one with a blood pressure of 108/74 and another with 94/68, and two instances with no reason documented. The resident's record did not show that the medical provider was notified to hold or not administer the medication. The DON stated the metoprolol order should have included parameters for when to hold the medication and that staff should have called the provider to obtain an order to hold it.
G-tube Feeding Not Administered as Ordered
Penalty
Summary
The facility failed to administer gastric tube feeding as ordered by the physician for one resident with epilepsy and gastrostomy (g-tube) status. The resident had a physician's order dated 4/21/25 for Glucerna 1.5 at 50 mL per hour with 45 mL water flushes per hour, and the care plan identified her as at nutritional risk due to dependence on enteral nutrition and directed staff to provide enteral feedings as ordered. On 7/25/25, the resident was observed in bed with the g-tube feeding pump running at 55 mL per hour. On 7/28/25, the resident was again observed with the feeding running at 55 mL per hour and water flushes at 40 mL per hour; the RN checked the order and confirmed the feeding should have been 50 mL per hour with 45 mL water flushes per hour, then stated the rate would be adjusted to match the order. The facility's Enteral Therapy Policy stated that a licensed nurse will take, note, and implement physician orders for enteral therapy.
Failure to document and care-plan intrusive wandering and resident-to-resident behaviors
Penalty
Summary
The facility failed to provide adequate supervision for a resident with dementia and intrusive wandering, failed to document new behavior events in the clinical record, and failed to timely update the plan of care with new interventions for behaviors for two residents. Resident K had diagnoses including dementia with behavioral disturbances, anxiety, and traumatic brain injury, and his MDS indicated severe cognitive impairment, inattention, physical behaviors, and daily wandering. His care plan identified that he would wander into rooms on the secured unit and included interventions such as addressing immediate needs, encouraging activities, ensuring safety, using a calm approach, and removing him from the immediate area to evaluate needs. Resident K was observed attempting to enter another resident’s room and was redirected. The clinical record later documented a resident-to-resident incident involving Resident K and another resident, with a small scratch noted on Resident K’s hand, but Resident K’s record did not include a Behavior Communication Note or documentation about the reportable incident. Resident 61’s record also did not include documentation of the incident, a New Behavior Event, or a Behavior Communication Note. The record further showed repeated episodes of Resident K pacing, wandering into rooms, following other residents, and requiring redirection, 15-minute checks, and PRN lorazepam. An IDT review of the incident or the intrusive wandering was not documented, and a care plan addressing intrusive wandering was not initiated until later. Resident 61 had diagnoses including dementia with psychotic disturbance, short- and long-term memory problems, and delusions. Her care plan addressed a prior altercation with a peer, but it had not been updated to reflect the later incident with Resident K. The record showed that Resident K continued to wander into rooms and follow residents, and later Resident 61 shoved Resident K after he followed her in the hallway, causing him to fall against an elevator wall and slide to his coccyx. During interview, staff stated Resident K had always wandered into other residents’ rooms and that Resident 61 was not normally aggressive with other residents. The facility policy stated that new, worsening, or high-risk behaviors, including intrusive wandering and behaviors directed at another resident, required a New/Worsening Behavior Event and IDT review, but those steps were not documented for the incident involving these two residents.
Failure to Obtain Timely Treatment Orders for Surgical Wounds
Penalty
Summary
The facility failed to timely identify and obtain physician's orders for a surgical wound present upon admission for a resident. The resident, who had a history of an anal abscess and colostomy, was admitted with a significant wound on her right buttock. Despite the presence of this wound, the facility did not have a treatment order for it upon admission. The admitting nurse attempted to contact the discharging hospital for treatment orders but was unsuccessful, and the orders were not obtained until two days later. The resident also had a dehisced abdominal wound, which was initially mistaken for a second ostomy by the nursing staff. This misunderstanding led to inadequate care for the wound, as it was covered with an ostomy bag instead of being treated as a surgical wound. The facility's staff did not obtain a physician's order for the abdominal wound upon admission, and it was not until several days later that the wound's condition worsened, prompting a hospital transfer. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's wound care needs. The Assistant Director of Nursing Services and other staff members acknowledged the oversight in obtaining timely treatment orders and the misinterpretation of the resident's abdominal wound. The facility's policies required a thorough assessment and notification of the physician for treatment orders upon admission, which was not followed in this case.
Failure to Provide Transportation for Resident's Medical Appointments
Penalty
Summary
The facility failed to ensure that Resident C, who required follow-up care with an ENT physician, was provided with transportation to attend scheduled medical appointments. Resident C had a complex medical history, including malignant neoplasm of the oropharynx, tongue cancer, and hydrocephalus, and resided on the ventilator unit. The clinical record indicated several missed appointments due to the lack of transportation arrangements, despite the resident's need for a respiratory therapist to accompany him. The facility's Executive Director and Director of Nursing acknowledged the lapses in coordination and communication that led to the missed appointments. The ED indicated that the previous RT manager was responsible for ensuring transportation and accompaniment by an RT, but failed to do so. The DON noted that the admitting nurse should have reviewed the discharge summary to ensure follow-up appointments were scheduled, but this was not done. Additionally, the facility's transportation provider confirmed that no attempts were made to arrange transportation for several appointments. The facility's Scheduled Appointment Policy outlined the procedures for maintaining continuity of care during outside appointments, including documenting appointments in the electronic medical record and reviewing them during administrative meetings. However, these procedures were not followed, resulting in Resident C missing multiple critical medical appointments. The report highlights the facility's failure to adhere to its own policies, leading to a deficiency in providing necessary care for Resident C.
Resident Falls Due to Improper Use of Mechanical Sling Lift
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer using a mechanical sling lift, resulting in the resident falling to the floor. The incident involved a resident with cerebral palsy, muscular dystrophy, and contractures, who required a mechanical lift for transfers. During the transfer, a certified nursing assistant (CNA) did not secure the sling clip properly to the peg on the lift, causing the resident to fall and sustain injuries, including pain in the head, neck, and back, and a small amount of bleeding from the head. The resident was subsequently transferred to a local emergency room. The Director of Nursing and the Regional Nurse Consultant demonstrated the operation of the mechanical lift and confirmed that the clip strap was not locked in place, leading to the fall. The CNA involved in the incident reported previous difficulties with the clip straps not locking properly and believed it was due to a faulty pad. Despite being trained on the lift's operation, the CNA continued to experience issues with securing the clip. The instructional video for the sling lift indicated the proper method for securing the clip, which was not followed in this instance.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to properly store foods in the kitchen, affecting 60 residents who consume food prepared there. During an initial tour of the kitchen, several deficiencies were observed. In the walk-in fridge, a metal pan containing a package of meat was found thawing without a label indicating the type of meat and the date it was removed from the freezer, which is necessary to ensure its use within 72 hours of thawing. Additionally, two unopened half gallons of lactose-free milk were found to be expired, and two unopened gallon jugs of milk were improperly stored on the floor of the fridge. A tray on a multi-shelf rack contained pre-poured glasses of milk and orange juice that were not labeled, despite the tray being marked with a use-by date. Other observations included the Dietary Manager's mustache not being covered by a hair net, despite being more than an inch long, and a large trash can not in use was found without a lid. The facility's Food Storage policy requires that food be stored at appropriate temperatures and methods to prevent contamination, with items clearly labeled with the name, preparation date, and consumption or discard date. The policy also specifies that food should be stored a minimum of six inches above the floor and that thawed items should be used within 72 hours unless otherwise specified by the manufacturer. The Retail Food Establishment Sanitation Requirements also mandate that receptacles containing food residue be kept covered when not in continuous use.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of damaged and unclean conditions in resident rooms and common areas. Specific issues included splintered chair rails, chipped walls with exposed drywall, and exposed wires from telephone jacks in several residents' rooms. Additionally, there were reports of mismatched and loose flooring, worn and scratched furniture, and stained bed linens and towels. These deficiencies were observed in the rooms of ten residents, indicating a widespread issue within the facility. The facility also failed to ensure that equipment and furnishings were clean and well-maintained. Observations included wheelchairs with dried substances on the wheels, feeding pump poles with stains and dried formula, and floors with brown spots. The facility's housekeeping practices were inadequate, as noted by a registered nurse who reported that rooms were not being thoroughly cleaned and that there were staffing issues in the housekeeping department. The executive director acknowledged these ongoing problems during an environmental tour, noting that some repairs and cleaning had not been completed as required. Interviews with residents and family members further highlighted the facility's failure to provide a clean environment. Complaints were made about stained linens and the worn appearance of furniture, particularly on the vent unit. The facility's deep cleaning schedule was found to be lacking, with no logs available to track when deep cleaning had been completed. The facility's policy required monthly deep cleaning and the use of a quality control checklist, but these procedures were not being followed, contributing to the deficiencies observed.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) determined and documented a self-medication assessment for a resident who was observed with medications by their side in a common area. During a random observation, a resident was found sitting in a lounge with a medication cup containing several unidentified pills. The resident expressed concern about the number of medications and refused to take them without knowing what they were. An LPN, who had administered the medications, believed the resident had taken them, but the resident denied spitting them out and stated she had not attempted to take them due to her concerns. Upon reviewing the resident's clinical record, it was found that there was no Self-Administration of Medication assessment documented. The resident's diagnoses included paranoid schizophrenia, anxiety disorder, and major depressive disorder, and she had a moderate cognitive deficit according to a recent assessment. Additionally, the resident's care plan did not include any information regarding her ability to self-administer medications. The facility's policy requires that alert residents be informed of their right to self-administer medications and that an assessment be conducted by the IDT, but this was not done for the resident in question.
Failure to Ensure Functioning Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that low air loss (LAL) mattresses were functioning properly for two residents with pressure ulcers. Resident D, who had diagnoses including hypertension, congestive heart failure, diabetes mellitus, and muscle weakness, was observed multiple times over two days lying on a mattress with a pump that was not functioning, as indicated by the absence of lights on the pump. The resident's care plan required the use of a pressure-reducing mattress due to impaired skin integrity and limited mobility. It was only after a respiratory therapist checked the outlet and plugged the mattress in properly that the pump began to function. Similarly, Resident 45, who had a history of chronic respiratory failure, congestive heart failure, and multiple pressure ulcers, was also found with a non-functioning LAL mattress. The resident's care plan included the use of a pressure-reducing mattress due to a history of pressure injuries. The issue was identified when the respiratory therapist discovered that the plug connecting the pump to the mattress had come undone. Once reconnected, the mattress began to function as intended. The facility's policy on wound prevention required the use of pressure redistribution mattresses for all residents, but this was not adhered to in these cases.
Resident Falls Due to Loose Flooring
Penalty
Summary
The facility failed to maintain safe flooring conditions, leading to an accident involving a resident, identified as Resident E. Resident E, who had a history of chronic respiratory failure, tracheostomy status, dependence on a ventilator, muscle weakness, morbid obesity, and diabetes mellitus, required assistance with activities of daily living (ADLs) such as bed mobility, transfers, and toileting. During an interview, Resident E reported tripping on a piece of flooring that was not level, which caused her to fall while attempting to transfer from her wheelchair to her bed. The bed was not locked at the time, contributing to her fall. The flooring issue was confirmed by an observation that noted mismatched wood flooring under the wheels of Resident E's bed. The incident was documented in a fall event report, which indicated that Resident E tripped on a loose floorboard. Maintenance was notified and subsequently repaired the flooring. An interdisciplinary team note identified the root cause of the fall as the loose flooring. A registered nurse confirmed that the flooring had been coming up throughout the unit, starting on the 4th floor and affecting the unit where Resident E resided. The facility's Fall Management policy, revised in August 2022, emphasized the importance of providing adequate supervision and assistance to prevent falls, but this was not effectively implemented in this case.
Infection Control and Catheter Care Deficiency
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinence care and did not ensure appropriate follow-up for changes in urinary output from an indwelling urinary catheter for a resident. The resident, who had multiple diagnoses including respiratory failure, diabetes mellitus, obesity, and neuromuscular dysfunction of the bladder, was dependent on a ventilator and had an indwelling catheter. During a bed bath, a CNA was observed using the same part of a washcloth to clean the resident's perineal area twice, and improperly positioned the urinary catheter bag above the level of the bladder, which is against the care plan instructions. Further observations revealed that the urinary catheter tubing contained a milky and gray liquid, which later turned cloudy and dark yellow, and eventually showed clumps of a white substance. The RN noted sediment in the catheter tubing and bag, indicating a potential issue with sediment in residents with long-term indwelling catheters. Despite a previous progress note indicating clear urine, the facility did not communicate these changes to the physician or family as required by their Change of Condition Policy.
Deficiencies in Tracheostomy Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents with tracheostomies, as evidenced by multiple deficiencies observed during tracheostomy care. For Resident D, respiratory therapists did not maintain proper infection control practices. They used the same gloves for multiple tasks, including removing the inner cannula, handling soiled gauze, and applying a new trach collar. Additionally, sterile gloves were contaminated during the procedure, and the inner cannula was not replaced immediately after removal, violating the facility's tracheostomy care competency guidelines. Resident E's care was also deficient, as the facility did not adhere to the physician's order to change oxygen tubing weekly. Observations revealed that Resident E was wearing a trach collar dated several weeks prior, indicating that the tubing had not been changed as required. This oversight suggests a lapse in following prescribed respiratory care protocols, potentially compromising the resident's respiratory health. For Resident 60, the facility failed to document a comprehensive assessment after the resident's trach was inadvertently removed and reinserted by an LPN. The clinical record lacked details on the resident's tolerance of the procedure, the appearance of the stoma, and any potential concerns following the incident. This omission contravenes the facility's policy, which mandates thorough documentation of tracheostomy care, including any changes in the resident's condition or complications arising from the care provided.
Failure to Obtain Timely Laboratory Tests
Penalty
Summary
The facility failed to timely obtain laboratory tests as ordered by the physician for a resident with multiple diagnoses, including diabetes, hypertension, and epilepsy. The resident's care plan, initiated in 2018, included interventions to obtain labs as ordered to maintain adequate tissue perfusion. However, the clinical record did not contain laboratory results for the tests scheduled on March 29, 2024, which included a CBC with differential, CMP, HgbA1c, TSH, vitamin D level, valproic acid level, and a lipid profile. Interviews conducted during the investigation revealed that the Assistant Director of Nursing was unaware of why the labs were not drawn, and the Laboratory Associate confirmed that no lab orders were recorded for the specified date. The facility's guidelines for lab and radiology tracking require that all lab orders be entered into the system and the lab provider be notified, but this process was not followed, leading to the deficiency.
Infection Control Deficiencies in Medication Administration and PPE Use
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration and personal care activities. During a bed bath for Resident F, a CNA used the same gloves and washcloth to clean different areas of the resident's body, including the anal area and posterior thighs, without changing gloves or performing hand hygiene. This was contrary to the facility's skills competency document, which required changing gloves and performing hand hygiene after changing bath water and providing perineal care. Additionally, during medication administration, an LPN was observed placing his fingers inside medication cups and pill crusher sleeves, which is not in line with proper infection control practices. The LPN also failed to perform hand hygiene before donning and after doffing gloves while preparing medications for multiple residents. The facility lacked a specific policy regarding the handling of medication cups and pill crusher sleeves, and the nursing skills competency for gloves emphasized the importance of hand hygiene before and after glove use. Furthermore, the facility did not ensure that PPE was available outside the room of Resident 56, who was on transmission-based precautions for a contagious infection. The PPE cart was located inside the resident's room, contrary to the facility's policy, which required PPE to be available outside the room for staff to don before entry. Staff members, including a CNA and a respiratory therapist, were observed entering the room without donning PPE beforehand, which was against the facility's transmission-based precautions policy.
Lack of Privacy Curtains in Shared Rooms
Penalty
Summary
The facility failed to ensure privacy curtains were present in rooms shared by two residents, affecting four of the fifteen residents reviewed for environmental conditions. Resident 14, who was cognitively intact, and Resident 36 shared a room that lacked a privacy curtain between their beds. During an observation with the Executive Director, Resident 14 confirmed that the privacy curtain had been missing for an extended period. Similarly, Resident 43, with an anoxic brain injury, and Resident 53, who had moderately impaired cognition due to diabetes, shared a room where the privacy curtain was absent on the doorway side of Resident 53's bed. Resident 53 reported that the privacy curtain had never been present since his admission to the room. The Executive Director acknowledged that resident rooms should have privacy curtains.
Deficiencies in Resident Care and Hygiene
Penalty
Summary
The facility failed to provide adequate care for three residents in terms of oral hygiene, complete bed baths, hair care, and emptying of bedside commodes. Resident D, who had diagnoses including hypertension, congestive heart failure, and diabetes mellitus, was observed multiple times with a white coated substance on his tongue and foam in his mouth, despite a physician's order for oral care three times a day. This indicates a lack of adherence to the care plan for oral hygiene. Resident E, with chronic respiratory failure and dependence on a ventilator, was found with a bedside commode containing yellow liquid that had not been emptied for several hours, despite requiring substantial assistance with toileting hygiene. Resident F, who was dependent on a ventilator and had multiple health issues including respiratory failure and obesity, was observed receiving an incomplete bed bath. The CNA did not wash Resident F's face, hair, or legs below the knees, and her hair appeared greasy and unkempt over several days. The last recorded instance of hair washing was weeks prior, indicating neglect in personal hygiene care. These observations highlight the facility's failure to provide necessary assistance with activities of daily living for these residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tranquility Nursing And Rehab | 2.1 mi | — | 0 | 0 |
| Alpha Home - A Waters Community | 2.3 mi | ★★★★★ | 17 | 0 |
| Westpark A Waters Community | 2.9 mi | ★★★★★ | 2 | 0 |
| Creekside Health And Rehabilitation Center | 4.2 mi | ★★★★★ | 11 | 0 |
| American Village | 4.4 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.