Inspection Reports for Capital Nursing And Rehabilitation Center
3000 Holston Ln, Raleigh, NC 27610, United States, NC, 27610
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication management, pressure ulcer care, wound treatment, and resident safety at Capital Nursing and Rehabilitation Center.
Findings
The facility was found deficient in several areas including failure to ensure time-limited physician orders for PRN psychotropic medications, incomplete weekly pressure ulcer assessments, failure to complete required Abnormal Involuntary Movement Scale (AIMS) assessments for residents on antipsychotic medications, and inaccurate transcription of wound treatment orders. These deficiencies were associated with minimal to potential minimal harm and affected a few to some residents.
Deficiencies (4)
Failed to ensure a physician order for an as needed (PRN) psychotropic medication was time limited in duration for 1 of 5 residents reviewed for unnecessary medications (Resident #90).
Failed to consistently complete a thorough weekly pressure ulcer assessment that included type of injury, stage, description, presence of pain, and dressing or treatment for 1 of 2 residents observed for pressure ulcers (Resident #3).
Failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident #82).
Failed to accurately transcribe wound treatment orders for 1 of 2 residents reviewed for wound care (Resident #1).
Report Facts
Residents reviewed for unnecessary medications: 5
Residents observed for pressure ulcers: 2
Residents reviewed for wound care: 2
Dates of wound physician assessments: 13
Pressure ulcer measurements: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication order reviews and AIMS assessment completion |
| Consultant Pharmacist | Consultant Pharmacist | Conducted medication regimen reviews and identified missing stop dates and AIMS assessments |
| Administrator | Administrator | Interviewed regarding clinical meetings and order transcription oversight |
| Wound Treatment Nurse | Wound Treatment Nurse | Responsible for wound assessments and documentation; interviewed about pressure ulcer care |
| Treatment Nurse | Treatment Nurse | Interviewed about wound care order transcription and wound treatment observation |
| Wound Physician | Wound Physician | Provided weekly wound assessments and interviewed about order transcription errors |
| Corporate Clinical Specialist | Corporate Clinical Specialist | Interviewed regarding review of weekly pressure ulcer assessments |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 25, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to a fall incident involving Resident #3 on 5/20/25 during wound care, where the resident was left unattended and fell from the bed requiring hospital transfer.
Complaint Details
The complaint investigation was substantiated. Resident #3 fell from bed on 5/20/25 when left unattended by MD #1 during wound care. The fall was unwitnessed but confirmed by staff and video footage. Resident #3 was transferred to the hospital for evaluation with no injuries found. Immediate education was provided to involved staff and systemic corrective actions were implemented.
Findings
The facility failed to provide safe care when Resident #3 was left unattended on the edge of the bed during wound care by Physician MD #1, resulting in a fall. The investigation included interviews, record reviews, and video footage. Immediate education and corrective actions were implemented, including staff training and monitoring to prevent recurrence.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in Resident #3 falling from bed.
Report Facts
Residents affected: 1
Date of fall incident: May 20, 2025
Date of survey completion: Jun 25, 2025
Bed elevation: 18
Education completion date: May 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD #1 | Wound Care Physician | Left Resident #3 unattended during wound care leading to fall |
| Nurse #2 | Treatment Nurse | Accompanied MD #1 during wound care and left room to get supplies |
| Nurse #1 | Completed fall report and assessed Resident #3 after fall | |
| Nurse Aide #1 | Nurse Aide | Cared for Resident #3 and stayed with her after fall until EMS arrived |
| Director of Nursing | Director of Nursing (DON) | Conducted post-fall investigation, provided education, and monitored corrective actions |
| Physical Therapist #1 | Physical Therapist | Provided therapy to Resident #3 and commented on her fall risk |
| Administrator | Facility Administrator | Participated in investigation and oversaw corrective action plan |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 16, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents, specifically focusing on the condition of caulking around toilets and baseboards in resident bathrooms.
Findings
The facility failed to ensure that the caulking around the base of toilets and baseboards in multiple bathrooms was adhered properly and free of black/brown matter, indicating water damage and cleanliness issues. Several residents and staff interviews confirmed the presence of detached caulking and black/brown matter, and maintenance staff acknowledged the need for replacement and repair.
Deficiencies (2)
Caulking around the base of toilets was detached in some areas with black/brown matter underneath in multiple resident bathrooms.
Baseboards in bathrooms had areas of dried black/brown matter due to water damage.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding the condition of caulking and baseboards, stating caulking was for appearance and needed replacement. | |
| Administrator | Interviewed about family concerns and facility response to caulking and baseboard issues. | |
| Maintenance Assistant | Interviewed about the condition of the toilet base caulking and need for replacement. |
Inspection Report
Routine
Deficiencies: 5
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care plan revisions, wound care treatment orders, pressure ulcer care, accident hazard prevention, and medical record accuracy at Capital Nursing and Rehabilitation Center.
Findings
The facility failed to revise care plans timely for behaviors and hospice services for two residents, failed to obtain and document wound treatment orders for a resident with cellulitis, failed to transcribe and implement wound care physician orders for a resident with pressure ulcers, and failed to provide a hazard-free environment to prevent a resident from ingesting a non-toxic liquid cleanser. The facility provided education to staff regarding entering wound treatment orders.
Deficiencies (5)
Failed to revise care plans for behaviors and hospice services for 2 of 21 residents reviewed.
Failed to obtain a treatment order prior to treating a wound for 1 of 4 residents reviewed for professional standards of practice.
Failed to transcribe physician treatment orders and failed to implement wound care doctor orders for 1 of 3 residents reviewed for pressure ulcers.
Failed to provide a hazard free environment to prevent an avoidable accident when a resident ingested a non-toxic liquid cleanser.
Failed to document wound treatment orders for 1 of 4 residents reviewed for medical record accuracy.
Report Facts
Residents reviewed for care plan revision: 21
Residents reviewed for wound treatment orders: 4
Residents reviewed for pressure ulcers: 3
Residents reviewed for supervision to prevent accidents: 4
Residents reviewed for medical record accuracy: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Notified Nurse Practitioner and Director of Nursing about Resident #13's ingestion incident; interviewed regarding incident and care plan revision | |
| MDS Nurse #2 | Responsible for updating care plans for Residents #13 and #14; missed initial updates but later corrected | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan revision responsibilities and wound treatment order deficiencies; provided education to Wound Treatment Nurse |
| Nurse Practitioner #1 | Notified about Resident #13's ingestion incident; provided clinical assessment | |
| Nurse Practitioner #2 | Provided visit note and interview regarding Resident #251's wound care | |
| Wound Treatment Nurse | Performed wound assessments and treatments; failed to enter wound treatment orders; interviewed multiple times | |
| Wound Provider | Interviewed regarding wound care referrals and treatment orders | |
| Medical Director | Interviewed regarding wound care and ingestion incident | |
| Nurse Aide #1 | Observed Resident #13 ingesting liquid cleanser | |
| Administrator | Interviewed regarding care plan revision responsibilities and wound treatment order policies |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 18, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding wound care, pressure ulcer care, accident prevention, and medical record accuracy for several residents at the facility.
Complaint Details
The complaint investigation involved review of records, staff and provider interviews, and observations related to wound care treatment orders, pressure ulcer care, accident prevention, and medical record accuracy for residents #251, #38, and #13. Substantiation status is not explicitly stated.
Findings
The facility failed to obtain and document physician treatment orders prior to wound care treatments for Resident #251, failed to transcribe and implement wound care physician orders for Resident #38, and failed to provide a hazard-free environment to prevent an avoidable accident involving Resident #13 ingesting a non-toxic liquid cleanser. The facility also failed to maintain accurate medical records regarding wound treatment orders for Resident #251.
Deficiencies (5)
Failed to obtain a treatment order prior to treating a wound for Resident #251.
Failed to document wound treatment orders and complete treatments as ordered for Resident #251.
Failed to transcribe physician treatment orders and implement wound care physician orders for Resident #38.
Failed to provide a hazard free environment to prevent an avoidable accident when Resident #13 ingested a non-toxic liquid perineal and skin cleanser.
Failed to maintain accurate medical records documenting wound treatment orders for Resident #251.
Report Facts
Wound measurements: 2
Wound measurements: 2.5
Dates of wound treatment orders: Jun 29, 2024
Dates of wound treatment orders: Jul 2, 2024
Dates of wound treatment orders: Jul 3, 2024
Incident date: Apr 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #5 | Nurse | Completed nursing admission review and weekly skin assessment for Resident #251 |
| Nurse Practitioner #2 | Nurse Practitioner | Provided visit note and interview regarding Resident #251's wound care |
| Wound Treatment Nurse | Wound Treatment Nurse | Evaluated and treated Resident #251 and Resident #38 wounds; responsible for wound treatment orders |
| Wound Provider | Wound Care Physician | Conducted wound rounds and provided treatment orders for Resident #38 |
| Medical Director | Medical Director | Interviewed regarding wound care and incident involving Resident #13 |
| Director of Nursing | Director of Nursing | Provided interviews regarding wound treatment orders and incident management |
| Administrator | Administrator | Interviewed regarding treatment orders and facility policies |
| Nurse #1 | Nurse | Notified Poison Control and documented incident involving Resident #13 |
| Nurse Aide #1 | Nurse Aide | Observed Resident #13 ingesting liquid cleanser |
| Nurse #4 | Nurse | Provided interview regarding Resident #251's wound treatment |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 9, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely written notification of discharge to residents, their representatives, and the ombudsman when residents were transferred to the hospital.
Complaint Details
The complaint investigation found that the facility failed to provide written discharge notifications to residents and their representatives and the ombudsman for hospital transfers. The facility was previously cited for this issue during a 7/1/21 survey, indicating a repeated deficiency.
Findings
The facility failed to provide written discharge notifications to three residents (Residents #48, #63, and #30) and the ombudsman as required. Additionally, the facility failed to administer enteral feeding at the correct physician-ordered rate for one resident (Resident #4). The Quality Assessment and Assurance Committee failed to sustain corrective actions related to discharge notifications, showing a pattern of ineffective quality assurance.
Deficiencies (3)
Failed to provide written notice of discharge to residents and their representatives and notification to the ombudsman for residents transferred to the hospital.
Failed to administer enteral feeding formula at the correct rate as ordered by the physician for one resident.
Failed to maintain implemented procedures and monitor interventions related to discharge notifications, indicating ineffective Quality Assessment and Assurance Program.
Report Facts
Residents reviewed for facility-initiated discharge: 3
Enteral feeding rate ordered: 50
Enteral feeding rate observed: 40
Date of hospital transfer: Feb 20, 2023
Date of hospital transfer: Jul 9, 2022
Date of hospital transfer: Jan 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Observed adjusting enteral feeding rate for Resident #4 and interviewed regarding feeding rate error | |
| Nurse #2 | Worked night shift and started enteral feeding bag at incorrect rate for Resident #4 | |
| Admissions Coordinator | Interviewed regarding discharge notification responsibilities | |
| Social Services Director | Interviewed regarding discharge notification awareness and responsibilities | |
| Administrator | Interviewed regarding failure to provide discharge notifications and staff turnover | |
| Director of Nursing | Interviewed regarding Resident #4's weight loss and enteral feeding rate |
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