Inspection Report
Complaint Investigation
Census: 54
Capacity: 64
Deficiencies: 4
Jun 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with care and medication administration requirements at the facility.
Findings
The inspection identified multiple deficiencies including failure to provide wound care as ordered, unlocked and unattended medication found accessible, incomplete medication administration records, and missing catheter care details in resident assessments. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating 'Reason: Complaint'.
Deficiencies (4)
| Description |
|---|
| Failure to provide ordered wound care services on specified dates. |
| Unlocked, unattended, and accessible medication found on the floor outside a resident's bedroom. |
| Medication administration records did not reflect that wound care services were provided on specified dates. |
| Resident assessment did not include catheter use details such as emptying, changing, and maintenance. |
Report Facts
Residents Served: 54
License Capacity: 64
Current Hospice Residents: 9
Residents 60 Years or Older: 54
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 58
Capacity: 64
Deficiencies: 7
Jan 22, 2025
Visit Reason
The inspection was conducted as a renewal inspection of THE TERRACES AT CAPITOL VILLAGE to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including delayed access to staff records, snow and ice obstructions on exit pathways, medication storage and labeling issues, missing blood glucose readings, inaccurate resident assessments, and illegible record entries. Plans of correction were accepted and reported as fully implemented by March 7, 2025.
Deficiencies (7)
| Description |
|---|
| Delayed and incomplete access to staff records for Staff Members A, B, and C. |
| Snow and ice covering exit pathways from the northern courtyard and west stairwell by Room 110. |
| Loose white rectangular pill with inscription '220' found in 3rd floor medication cart. |
| Pharmacy labels for multiple residents' medications did not include current instructions for administration. |
| Missing blood glucose readings between 1/8/2025 and 1/22/2025 for Resident #4; discrepancies in recorded readings. |
| Resident #3's assessment and support plan did not reflect updated immobility status. |
| Hand-written entries in residents' records were not dated, signed, or did not include full name and title of the person making the entry. |
Report Facts
Total Daily Staff: 68
Waking Staff: 51
Residents Served: 58
License Capacity: 64
Hospice Residents: 9
Residents Age 60 or Older: 58
Residents with Mental Illness: 1
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Named in medication storage, labeling, and glucometer reading findings and corrective actions | |
| Executive Director | Named in multiple findings related to access to records, snow removal, medication storage, resident assessments, and record entries | |
| HR Director | Named in staff records access deficiency and corrective actions | |
| Maintenance Supervisor | Named in snow and ice removal deficiency and corrective actions |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 64
Deficiencies: 0
Oct 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 10/22/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related; however, no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
Resident census served: 57
Licensed capacity: 64
Residents aged 60 or older: 62
Residents with physical disability: 1
Residents with mobility need: 10
Residents with current reidentification: 6
Inspection Report
Complaint Investigation
Census: 61
Capacity: 64
Deficiencies: 5
Aug 14, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 08/14/2024 and 08/16/2024 to review compliance and follow-up on a plan of correction submission.
Findings
The inspection identified multiple deficiencies including financial abuse by a staff member, mistreatment of a resident by staff mocking behaviors, incomplete resident assessments and support plans, and missing signatures on support plans. Plans of correction were accepted and implemented by 10/04/2024.
Complaint Details
The visit was complaint-related involving allegations of financial abuse by Staff Member A and mistreatment by Staff Members B and C. Both investigations resulted in staff suspension and separation from employment. The incidents were reported to DHS, Protective Services, and police as applicable.
Deficiencies (5)
| Description |
|---|
| Staff Member A attempted to cash two forged checks belonging to a resident without knowledge, constituting financial abuse. |
| Staff Members B and C mocked a resident's behaviors and were unprofessional, causing the resident to feel unsafe. |
| Resident's initial assessment and support plan did not document use and risks of an enabler bar device. |
| Resident support plan did not reflect physical assistance needed for safe transfers and ambulation. |
| Resident support plan was not signed by the assessor or resident, with no notation regarding inability or refusal to sign. |
Report Facts
License Capacity: 64
Residents Served: 61
Total Daily Staff: 68
Waking Staff: 51
Hospice Residents: 4
Residents Age 60 or Older: 61
Residents with Mental Illness: 1
Residents with Mobility Need: 7
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 58
Capacity: 64
Deficiencies: 4
Feb 7, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation of THE TERRACES AT CAPITOL VILLAGE facility on 02/07/2024 and 02/08/2024.
Findings
The inspection found multiple deficiencies including lack of carbon monoxide detectors near gas stoves, inoperable bathroom ventilation fans on the 2nd and 3rd floors, and medication storage and administration issues including incorrect recording of blood glucose readings and failure to administer prescribed medications as ordered.
Complaint Details
The inspection included a complaint investigation component as indicated by the inspection reason and findings related to medication administration and storage.
Deficiencies (4)
| Description |
|---|
| No carbon monoxide alarms were installed near the two gas stoves in the main kitchen as required by the Care Facility Carbon Monoxide Standards Act. |
| The main bathrooms on the 2nd and 3rd floors lacked operable ventilation fans and had no windows. |
| Medications for Resident 2 were not available in the home as prescribed, and blood glucose readings for Resident 1 and Resident 3 were incorrectly recorded or not recorded on the medication administration record (MAR). |
| Resident 1 was prescribed medication twice daily but was not administered the medication on specified dates. |
Report Facts
License Capacity: 64
Residents Served: 58
Total Daily Staff: 68
Waking Staff: 51
Current Residents in Hospice: 7
Residents Age 60 or Older: 58
Residents with Mobility Need: 10
Residents Diagnosed with Mental Illness: 1
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 48
Capacity: 64
Deficiencies: 9
Apr 13, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of THE TERRACES AT CAPITOL VILLAGE facility on 04/13/2023 and 04/20/2023 to review compliance and verify the submitted plan of correction.
Findings
Multiple deficiencies were identified including fire safety documentation issues, medication management errors such as discontinued and unlabeled medications, improper storage and calibration of glucometers, failure to follow prescriber's orders, and incomplete preadmission screening forms. The facility submitted plans of correction which were accepted and later implemented.
Deficiencies (9)
| Description |
|---|
| Accumulation of lint in the lint trap of the dryer in the third-floor laundry room. |
| Exit route used for evacuation and total number of residents evacuated were not documented on fire drill records. |
| Discontinued medication found in the medicine cart not on Medication Administration Record. |
| Insulin pens in medication cart were not labeled with the date they were opened. |
| Unopened expired medication found in the medication cart. |
| Over-the-counter medication found unlabeled with resident's name or identifying characteristics. |
| Blood glucose readings on Resident #3's glucometer were incorrectly recorded on the MAR; other residents' glucometers were not calibrated for correct time. |
| Medications were not administered to residents as prescribed, including blood sugar checks and topical treatments. |
| Preadmission screening forms for Residents #9 and #10 were incomplete and did not include determination that resident needs can be met by the home. |
Report Facts
License Capacity: 64
Residents Served: 48
Total Daily Staff: 53
Waking Staff: 40
Current Residents in Hospice: 6
Residents Age 60 or Older: 48
Residents with Mobility Need: 5
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Named in multiple medication management deficiencies and corrective actions. | |
| Executive Director | Named in fire drill record deficiencies, medication management, and preadmission screening corrective actions. | |
| Maintenance Director | Named in lint removal and fire drill record deficiencies and corrective actions. | |
| Vice President of Plant Operations | Involved in discussion and corrective actions related to fire drill record deficiencies. |
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