Health inspection·November 14, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of one residents reviewed for self-administration of medications (Resident 103).Findings include: Review of facility policy, titled Self-Administration of Medications, dated February 2021, revealed, in part, If it is deemed safe and appropriate for a resident to self -administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. Review of Resident 103's clinical record revealed diagnoses that included hypertension (high blood pressure) and depression. Review of Resident 103's physician orders revealed an order for May keep poured meds at bedside until he is able to take them, dated May 29, 2024. Review of Resident 103's care plan revealed a focus for I chose to self-administer my own medications with an initiated date of April 11, 2024. Interventions included, but were not limited to, Complete a Medication Self-Administration assessment prior to allowing self-administration, quarterly, and with significant change in condition, with an initiated date of April 11, 2024. Review of Resident 103 clinical record revealed that his Self-Administration of Medications Evaluation was last completed on April 11, 2024. During a staff interview with Employee 4 (Regional Director of Clinical Services) on November 14, 2025, at 1:25 PM, Employee 4 confirmed there were no recent Self-Administration of Medications Evaluations completed for Resident 103. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 4 on November 14, 2025, at 1:58 PM, the NHA confirmed that Resident 103 should have had a Self -Administration of Medications Evaluation completed at least quarterly. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(d) Resident care Policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. Residents Affected - Some Page 1 of 5 395372 395372 11/14/2025 Capitol Rehabilitation and Healthcare Center 4000 Linglestown Road Harrisburg, PA 17112

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, document review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on one of three nursing units (three shower rooms on the north unit and one resident bathroom on the north unit).Findings include: During an interview with Resident 24 on November 12, 2025, at 11:00 AM, the resident stated that the shower room in the northwest hall needed to be repaired; there were holes in the flooring. During an interview with Resident 120 on November 12, 2025, at 11:30 AM, the resident stated that the shower room on the northeast hall needed to be cleaned. Observation in the Northwest shower room on November 12, 2025, at 11:45 AM, revealed there were holes in the flooring an inch and a half a quarter way around the drain (down to the tile floor) and in two areas in front of the shower: an inch and a half by four inches and two by three inches. Observation in the Northeast front shower room on November 12, 2025, at 11:45 AM, revealed the bottom of the shower curtain contained black substance, the lip to the shower and along the non-skid tape inside the shower contained a black substance, and the shower head was removed from the hose and was on the sink counter (the thread on the shower head was inside the hose). Observation in the Northeast rear shower room on November 12, 2025, at 11:50 AM, revealed there was no caulk in front of the shower, and the inside of the shower floor was chipped. Observation of the above shower rooms with the Nursing Home Administrator (NHA) on November 13, 2025, at 9:00 AM, revealed the shower rooms were as stated above. At that time, the NHA revealed the shower rooms were scheduled to be renovated, the Guild shower room was in the process of being renovated, and one shower room on the South unit had already been renovated. Interview with the NHA on November 14, 2025, at 2:25 PM, revealed that the shower rooms should be clean, and the shower head and curtain should've been replaced. During an interview with Resident 136, on November 12, 2025, at 11:59 AM, she reported that the shower in her bathroom was dirty with water sitting in it. She indicated that it had been like that for weeks and that she had been asking for someone to fix it. She said that the smell upset her stomach. Immediate observation of Resident 136's bathroom at 12:01 PM, revealed the shower stall had no shower head and the waterspout was plugged off. There was brown colored water sitting on the floor of the shower. The shower drain was closed off with a bolt. The vented drain covered was removed and laying on the soap dish of shower wall. There was a strong, offensive odor noted. During a follow-up observation of Resident 136's bathroom on November 13, 2025, at 8:57 AM, the same findings were noted. During an observation with the NHA on November 13, 2025, at 9:37 AM, the NHA indicated that she thought the plumber had been called to address the issue but would follow-up. During a staff interview with the NHA, Director of Nursing (DON), and Employee 4 (Regional Director of Clinical Services on November 13, 2025, at 2:10 PM, the NHA Indicated that she had spoken to the facility's maintenance director regarding the drain in Resident 136's shower. She said that maintenance went and looked at the drain and removed the bolt that was plugging the drain. She indicated that the water drained out with no issues. The NHA said she was not sure why the drain was closed off. She said that the shower had now been cleaned, and the vented drain plate was placed. Review of facility provided Housekeeper 3 cleaning checklist for November 12, 2025, revealed that a housekeeper had completed cleaning of Resident 136's room. 28 Pa. Code 201.18 (b)(1)(3) (e)(2.1) Management 395372 Page 2 of 5 395372 11/14/2025 Capitol Rehabilitation and Healthcare Center 4000 Linglestown Road Harrisburg, PA 17112

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, review of select employee files, and a staff interview, it was determined that the facility failed to verify if individuals have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property for four of five employee files reviewed (Employees 5, 6, 7, and 8).Findings include:Review of facility policy, titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed October 9, 2025, read, in part, Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property; a disciplinary action taken against his or her professional license by a state licensing body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of select facility documentation provided revealed Employee 5 (Registered Nurse) had an original hire date of October 9, 2025. Upon request, the facility was not able to provide evidence that a criminal background check was requested prior to hire.Review of select facility documentation provided revealed Employee 6 (Nurse Aide) had an original hire date of August 14, 2025. Upon request, the facility was not able to provide evidence that a nurse aid registry verification was performed prior to hire. Review of select facility documentation provided revealed Employee 7 (Nurse Aide) had an original hire date of September 4, 2025. Upon request, the facility was not able to provide evidence that a nurse aid registry verification was performed prior to hire. Review of select facility documentation provided revealed Employee 8 (Licensed Practical Nurse) had an original hire date of October 16, 2025. Upon request, the facility was not able to provide evidence that a professional license verification was performed prior to hire. Interview with Employee 4 (Regional Director of Clinical Services) and the Nursing Home Administrator (NHA) on November 14, 2025, at 1:02 PM, revealed the employee files reviewed were prepared by the previous Human Resources Director and they did not complete the license verification, nurse aide registry inquiries, or background check prior to hire. The NHA revealed she would expect license verification, nurse aide registry inquiries, and background checks to be completed prior to hire.28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Some 395372 Page 3 of 5 395372 11/14/2025 Capitol Rehabilitation and Healthcare Center 4000 Linglestown Road Harrisburg, PA 17112

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observations, facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 30 residents reviewed (Residents 5 and 84).Findings Include: Review of facility policy, titled Care Plans, Comprehensive Person-centered, revised March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of facility policy, titled Isolation- Categories of Transmission-Based Precautions, revised September 2022, failed to reveal any expectation of adding transmission-based precautions to a resident's care plan. Review of Resident 5's clinical record revealed diagnoses that included depression, dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 5's clinical record revealed that he began experiencing cognitive issues and behaviors around August 5, 2025, and that an anti-anxiety medication was ordered as well as a psychiatric consult. Further review of Resident 5's care plan failed to reveal a care plan focus for his dementia diagnosis or hisidentified target behaviors. During a staff interview with Employee 4 (Regional Director of Clinical Services) on November 14, 2025, at 1:30 PM, Employee 4 confirmed that the care had not been revised when behaviors started and dementia diagnosis added. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 4 on November 14, 2025, at 1:58 PM, the NHA confirmed that Resident 5's care plan should have been revised when the changes occurred. Review of Resident 84's clinical record revealed diagnoses that included cerebral infarction (the death of brain tissue caused by a lack of blood flow) and hemiplegia (paralysis affecting one side of the body, resulting in weakness, stiffness, and poor motor control on that side). Observation of Resident 84's room door on November 12, 2025, at 9:45 AM, revealed a sign signifying that Resident 84 was on contact precautions. Review of current physician orders for Resident 84 revealed a current order for contact precautions due to ESBL (Extended-Spectrum Beta-Lactamase, which are enzymes produced by bacteria that make them resistant to certain antibiotics). Review of Resident 84's care plan failed to reveal any indication that contact precautions need to be followed when caring for Resident 84. An interview with the NHA on November 14, 2025, at 12:15 PM, revealed that Resident 84 should have contact precautions included on their care plan. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. 395372 Page 4 of 5 395372 11/14/2025 Capitol Rehabilitation and Healthcare Center 4000 Linglestown Road Harrisburg, PA 17112

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, facility policy reviews, and staff interviews, it was determined that the facility failed to properly label drugs in one of three medication carts observed (North Unit West); failed to store medications properly in one of three medication carts observed (North Unit West); and failed to discard expired medications in one of three medication carts observed (Guild Unit) and one of two medication rooms observed (South Unit).Findings Include: Review of facility policy, titled Administering Medications, dated April 2019, revealed, in part, 13. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of facility policy, titled Medication Labeling and Storage, dated February 2023, revealed, in part, 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Observation of the North Unit [NAME] Medication Cart with Employee 1 (Licensed Practical Nurse) on November 13, 2025, at 9:00 AM, revealed a Lispro insulin pen for Resident 12 that was not dated with an open date or expiration date. In addition, an unopened Glargine insulin pen for Resident 9 was noted to be in the cart. The pharmacy sticker indicated that the medication was to be refrigerated until opened. Immediate interview with Employee 1 confirmed the findings and discarded Resident 12's Lispro insulin pen. She said that another nurse may have just pulled Resident 9's insulin pen from the medication refrigerator since the other pen was getting low. Observation of the South Unit Medication Room with Employee 2 (Registered Nurse) on November 13, 2025, at 9:37 AM, revealed two unopened bottles of Aspirin 325 mg tablets, both with a manufacturer expiration date of October 2025; and a bottle of Naproxen 220 mg tablets with an open date of February 20, 2025, and a manufacturer expiration date of September 2025. Employee 2 confirmed that the medications were expired and said she would discard them. Observation of the Guild Unit Medication Cart with Employee 2 on November 13, 2025, at 9:51 AM, revealed a bottle of guaifenesin 400 mg caplets with an open date of October 1, 2025, and a manufacturer expiration date of September 2025. Employee 2 confirmed that the guaifenesin tablets were opened after the manufacturer date. She further indicated that the resident that was taking this medication had just recently finished the course of treatment and that she did not think they had anyone else on this medication. She said she would discard the medication. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 4 (Regional Director of Clinical Services) on November 13, 2025, at 2:19 PM, the NHA confirmed that she would expect medications to be stored properly to include being discarded when expired. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. 395372 Page 5 of 5