Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Capital Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with an anxiety disorder was prescribed lorazepam, including a PRN order, without a required stop date for reassessment. The omission was identified during a consultant pharmacist's review, but the missing stop date was not initially flagged or corrected during routine clinical meetings, resulting in a deficiency related to the management of psychotropic medications.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing. Surveyors found that required interventions and monitoring were not consistently implemented.
A resident with severe cognitive impairment and a diagnosis of dementia was restarted on an antipsychotic medication, but the facility failed to complete the required AIMS assessment at initiation and did not perform ongoing monitoring as outlined in the care plan. The omission was attributed to a recent change in the facility's mental health and antipsychotic review process, which did not trigger the necessary assessment.
A resident with a sacral pressure ulcer and multiple comorbidities received wound care based on physician orders specifying calcium alginate with silver, but the facility failed to consistently and accurately transcribe these orders in the treatment records. The treatment nurse acknowledged the transcription error, and while the correct dressing was reportedly applied, documentation did not always match the physician's instructions. The DON and administrator confirmed that orders should be transcribed correctly.
A resident with severe cognitive impairment and poor balance, who was dependent for bed mobility, was left unattended on her side near the edge of the bed during wound care. Both the physician and nurse left the room to obtain supplies, leaving the resident in a vulnerable position, which resulted in a fall from the bed. The resident was assessed and sent to the hospital for evaluation, with no injuries found.
The facility failed to maintain clean and safe bathrooms in several resident rooms, with detached caulking and black/brown matter observed around toilet bases. Residents expressed dissatisfaction, and maintenance staff acknowledged the need for repairs. The Administrator admitted the need for more thorough inspections.
A resident with cellulitis of the right lower extremity was treated without a physician order at an LTC facility. The Wound Treatment Nurse assessed the wound as a pressure ulcer and initiated treatment without documentation in the TAR. The nurse later realized the wound was cellulitis but did not update records. The Medical Director confirmed antibiotics were the primary treatment, and the facility staff acknowledged the nurse's failure to document and follow protocol, leading to the deficiency.
A resident with a pressure ulcer did not receive care as per the physician's orders due to a failure in updating the treatment plan in the eMAR. The Wound Treatment Nurse applied Santyl based on wound observation without updating the orders, despite having discussed changes with the Wound Care Physician. The DON and Administrator noted the nurse should have documented and updated the orders.
A resident with severe cognitive impairment ingested a nontoxic liquid perineal and skin cleanser left within reach, mistaking it for a drink. The cleanser belonged to the resident's roommate and was used for stoma care. Staff interviews confirmed the resident had no history of ingesting non-food items and showed no adverse effects post-incident. The facility failed to maintain a hazard-free environment, leading to this avoidable accident.
A resident with cellulitis of the right lower extremity had wound treatments that were not documented in the Treatment Administration Record. The Wound Treatment Nurse evaluated the wound and decided to handle the treatments personally, but failed to enter the treatment orders into the system. This lack of documentation led to a deficiency in maintaining accurate medical records.
The facility failed to update care plans for two residents, one with behavioral issues and another receiving hospice services. A resident with Alzheimer's ingested a non-edible substance, but the care plan was not revised to prevent access to such items. Another resident was on hospice, yet their care plan did not reflect this change. The MDS Nurse was responsible for these updates but missed them despite discussions in clinical meetings.
PRN Psychotropic Medication Order Lacked Required Stop Date
Penalty
Summary
A deficiency occurred when a resident with an anxiety disorder was prescribed lorazepam, including a PRN (as needed) order, without a required time limitation or stop date. The resident was cognitively intact and had an active physician order for lorazepam 0.5 mg to be given twice daily and every 12 hours as needed for anxiety. The PRN order lacked a stop date, which is necessary for reassessment of the continued need for the medication. The care plan noted the use of anti-anxiety medication and the risk for adverse side effects, with an intervention for the Consulting Pharmacist to review psychotropic medications quarterly and as needed for possible changes or reductions. The Medication Administration Records showed that the PRN lorazepam was administered once in July and not at all in August. During a monthly medication review, the Consulting Pharmacist identified the missing stop date and notified the facility, requesting clarification or discontinuation of the order. Interviews with the DON and Administrator revealed that medication orders were reviewed in daily and morning clinical meetings, but the missing stop date for the PRN lorazepam was overlooked due to the way the order was written and not flagged by the system.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions and monitoring for pressure ulcer prevention and treatment were not consistently carried out for affected residents.
Failure to Complete Required AIMS Assessment for Antipsychotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was prescribed an antipsychotic medication, quetiapine fumarate, for dementia with psychosis. The resident, who had severe cognitive impairment and a diagnosis of vascular dementia without behavioral disturbances, was restarted on quetiapine after a period of discontinuation. The care plan required an AIMS assessment every six months, and the facility's records indicated that the assessment was not completed when the medication was re-initiated, nor had it been completed up to the time of the survey. The Consultant Pharmacist confirmed that an AIMS assessment is required at the start of antipsychotic therapy and every six months thereafter, and noted that she had notified the facility's DON and Administrator when she identified the missing assessment during her monthly review. The DON and Administrator both acknowledged that the transition to a new Mental Health and Antipsychotic Review process may have caused the AIMS assessment to be missed for this resident, as the new process did not trigger the required assessment when the antipsychotic was restarted.
Failure to Accurately Transcribe Wound Care Orders
Penalty
Summary
The facility failed to accurately transcribe wound treatment orders for a resident with a history of hemiplegia, hemiparesis following a stroke, and Type 2 Diabetes Mellitus, who was at risk for pressure ulcers due to immobility and incontinence. The resident's care plan included specific wound care instructions for a sacral pressure ulcer, with orders from the wound physician to apply a primary dressing of calcium alginate with silver, covered by a secondary island dressing. However, review of the Treatment Administration Records (TARs) over several months revealed discrepancies in the transcription of these orders. At times, the TARs listed the dressing as simply 'calcium alginate' without specifying the inclusion of silver, and the frequency of application was inconsistently documented. The treatment nurse acknowledged the oversight in transcription, stating that although the order was not transcribed correctly, the correct treatment was provided. Observations and interviews confirmed that the wound was being treated with the correct dressing, but the documentation did not consistently reflect the physician's orders. The wound physician noted that the omission of 'silver' in the order transcription was likely an oversight and that while the use of regular alginate would not have been detrimental, the silver component provided additional antimicrobial protection. Both the DON and the facility administrator stated that physician orders should be transcribed accurately. The resident's wound was nearly healed at the time of the survey, but the failure to correctly transcribe and document the wound care orders constituted a deficiency.
Resident Left Unattended During Wound Care Results in Fall
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, severe cognitive impairment, poor balance, and unsteady gait was left unattended during wound care. The resident was dependent for bed mobility and transfers, and her care plan identified her as at risk for falls. During a wound care procedure, the resident was positioned on her right side near the edge of the bed, with the bed elevated and no bed rails in use. While the wound care physician and a nurse were present, the nurse left the room to obtain additional supplies at the physician's request. The physician remained with the resident initially but then also left the room to gather more supplies, leaving the resident unattended in a vulnerable position. The resident subsequently fell from the bed and was found on the floor by the physician upon returning to the room. The resident was assessed for injuries, and although no injuries were observed, she was sent to the hospital for further evaluation. Interviews with staff confirmed that it was standard practice not to leave residents in unsafe positions and to ensure they were safely positioned in the middle of the bed with the bed in the lowest position before leaving them unattended. The physical therapist and nurse aide both confirmed the resident's inability to maintain balance or reposition herself safely. The incident was witnessed and reported by multiple staff, and the facility's investigation confirmed that the resident was left unattended in an unsafe position, directly leading to the fall.
Deficient Bathroom Maintenance in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in several resident bathrooms, as observed by surveyors. In multiple rooms, the caulking around the base of the toilets was found to be detached, with black or brown matter present underneath. This issue was noted in rooms occupied by both cognitively intact and dependent residents. Resident interviews revealed dissatisfaction with the bathroom conditions, with one resident reporting that flooding from an adjacent shower contributed to the unsanitary conditions. The Maintenance Director and Maintenance Assistant acknowledged the poor condition of the caulking and the presence of water damage, indicating a need for replacement. Despite these observations, the Administrator and Maintenance Director initially downplayed the significance of the caulking, suggesting it was primarily for appearance. However, the Administrator later admitted that more thorough inspections were necessary to address these issues. The report highlights a lack of proactive maintenance and oversight in ensuring a clean and safe environment for residents.
Failure to Obtain Treatment Order for Wound Care
Penalty
Summary
The facility failed to obtain a treatment order prior to treating a wound for a resident with cellulitis of the right lower extremity. Upon admission, the resident had two open areas on the right lower leg, but the hospital discharge summary did not include wound treatment orders. The Wound Treatment Nurse assessed the wound and determined it was a pressure ulcer, initiating treatment without a physician order. The nurse did not document the treatment in the Treatment Administration Record (TAR) and relied on personal knowledge to manage the wound care schedule. The Wound Treatment Nurse admitted to not entering wound treatment orders into the system, as he typically handled treatments personally. He also failed to refer the resident to the Wound Provider for evaluation. The nurse later realized the wound was cellulitis, not a pressure ulcer, but did not update the documentation. The Medical Director confirmed that antibiotics were the primary treatment for cellulitis and was unaware of any topical treatment orders. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed that the Wound Treatment Nurse should have obtained and documented treatment orders to ensure proper care. The lack of documentation and failure to follow protocol led to the deficiency, as the nurse completed treatments without a physician order, and the facility did not have a clear record of the resident's wound care needs.
Failure to Implement Physician's Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to properly transcribe and implement the physician's treatment orders for a resident with a pressure ulcer. The resident, who was admitted with multiple diagnoses including stroke with hemiplegia and diabetes mellitus, was identified as having a pressure ulcer on the coccyx and was at risk for developing additional ulcers due to decreased mobility and incontinence. The care plan included applying a moisture barrier with each brief change and administering treatments as ordered by the physician. However, the electronic Medication Administration Record (eMAR) did not reflect the updated orders from the Wound Care Physician, which included the application of Santyl and a foam dressing. During an observation, the Wound Treatment Nurse deviated from the documented orders by applying Santyl based on the presence of slough, without having updated the eMAR to reflect this change. The Wound Care Physician confirmed that she had discussed the order changes with the nurse, who was responsible for entering the new orders into the system. The Director of Nursing and the Administrator both indicated that the nurse should have documented the conversation and updated the orders accordingly. The failure to update and follow the physician's orders led to a deficiency in the care provided to the resident.
Resident Ingests Non-Food Item Due to Cognitive Impairment
Penalty
Summary
The facility failed to provide a hazard-free environment for a resident with severe cognitive impairment, leading to an avoidable accident. The incident involved a resident diagnosed with Alzheimer's Disease, dementia, delusional disorder, and iron deficiency anemia, who ingested an unknown amount of nontoxic liquid perineal and skin cleanser. The cleanser was left within the resident's reach, and the resident mistook it for a drink due to her cognitive impairment. The incident occurred when a nurse aide observed the resident drinking the cleanser, which belonged to the resident's roommate and was used for cleaning around a stoma site. The nurse aide could not determine how much of the liquid was consumed, but noted that not much was missing from the bottle. The resident was sitting on the edge of the bed with the bedside table within reach, where multiple drinks and a snack had been left earlier by staff. Interviews with staff, including a nurse practitioner and the medical director, confirmed that the resident had no history of ingesting non-food items and did not exhibit any symptoms of nausea or vomiting following the incident. Poison Control confirmed the cleanser was non-toxic, and the resident was monitored for any adverse effects, which were not observed. The facility's failure to ensure the environment was free from accident hazards contributed to the resident's ingestion of the cleanser.
Failure to Document Wound Treatment Orders
Penalty
Summary
The facility failed to document wound treatment orders for a resident with cellulitis of the right lower extremity. The resident was admitted with two open areas on the right lower leg, and the nursing admission review noted that treatment was in place. However, the Treatment Administration Record (TAR) for June and July did not show any documentation of treatments being ordered or completed for the resident's wound. The Wound Treatment Nurse evaluated the wound and determined it was a pressure ulcer, but did not enter the treatment orders into the system, as he intended to handle the treatments personally every two days. The Nurse Practitioner noted a dressing in place during a visit, but could not recall specific details about the resident's condition. The Wound Treatment Nurse admitted to not documenting the treatment completion or entering the orders, which was confirmed during a follow-up interview. The Director of Nursing acknowledged that the Wound Treatment Nurse should have entered the treatment orders to ensure any nursing staff could complete the treatment as scheduled. The lack of documentation and failure to enter treatment orders led to the deficiency in maintaining accurate medical records for the resident.
Failure to Revise Care Plans for Resident Behaviors and Hospice Services
Penalty
Summary
The facility failed to revise the care plan for two residents, leading to deficiencies in addressing specific needs. Resident #13, diagnosed with Alzheimer's Disease, dementia, delusional disorder, and iron deficiency anemia, experienced an incident where they ingested a non-edible substance. Despite the incident being discussed in a clinical meeting, the care plan was not updated to include measures to prevent access to bath items, which was a necessary precaution given the resident's behavior. The MDS Nurse acknowledged the oversight, stating that the care plan was not updated until several days after the incident. Similarly, Resident #14, who was admitted with Alzheimer's Disease and dementia, had an active physician order for hospice services. However, the care plan did not reflect this significant change. Although hospice services were discussed in daily clinical meetings, the MDS Nurse failed to update the care plan to include hospice services. This oversight was recognized during staff interviews, where it was confirmed that the MDS Nurse was responsible for updating the care plan but missed doing so.
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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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Nursing homes near Raleigh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnybrook Rehabilitation Center | 0.2 mi | — | 0 | 0 |
| Tower Nursing And Rehabilitation Center | 1.2 mi | — | 2 | 0 |
| Raleigh Rehabilitation Center | 3.9 mi | — | 3 | 0 |
| The Cardinal At North Hills | 4.5 mi | — | 2 | 0 |
| Bloomsbury At Hayes Barton Place | 4.6 mi | — | 0 | 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 August 2026) and official state health department websites.