North Capitol Nursing & Rehabilitation Center
NORTH CAPITOL NURSING & REHABILITATION CENTER in INDIANAPOLIS, IN — inspection on January 29, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
residents' fentanyl patches, as ordered.
Cross Reverence F-F755-
The facility failed to implement pharmaceutical procedures that assured the accurate acquiring, receiving, dispensing, and administering of narcotic medication.
This Citation relates to Intake 2632048. 3.1-28(a)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/29/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
North Capitol Nursing & Rehabilitation Center
2010 N Capitol Ave Indianapolis, IN 46202
SUMMARY STATEMENT OF DEFICIENCIES
indicated the placement of Resident D's fentanyl patch was not verified on first shift on 9/12/25. An interview was conducted with the Director of Nursing Services (DNS) on 1/28/26 at 10:59 a.m.
The DNS indicated there were issues, involving two nurses and fentanyl patch diversion, on the unit where Resident C, Resident D, Resident E, and Resident F resided.
The Pain Management policy was provided by the DNS on 1/29/26 at 11:30 a.m. It indicated, It is the policy of [name of facility] to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management.Physician orders for pain medication will be prescribed based upon the resident's intensity of pain.A plan of care will be written with the initiation of pain medication and individualized to the resident.
This citation relates to Intake 2632048.3.1-37(a)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/29/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
North Capitol Nursing & Rehabilitation Center
2010 N Capitol Ave Indianapolis, IN 46202
SUMMARY STATEMENT OF DEFICIENCIES
narcotic logs monthly during pharmacy medication reviews, but she was unsure.
She discussed the missing fentanyl patches with Pharmacist 6, and he provided the delivery information for her during the investigation.
She discussed with Pharmacist 6 as to why the pharmacy would send more fentanyl patches, after they just sent a month's worth.
Since this occurred, she reviewed the narcotic logs more often.
Their nurse practitioner discussed the issue with her coworkers as well, in regard to notifying her if they received requests for narcotic prescriptions on the weekends.
They discovered most narcotic prescription requests from RN 2 and LPN 4 occurred on the weekend, when there was an on-call nurse practitioner working.
The facility's investigation proved there were unaccounted for fentanyl patches, based on the amount delivered minus what was ordered to be administered and the amount of fentanyl patches remining for each resident.
She and the ADNS interviewed RN 2 and LPN 4 about the fentanyl patches that were unaccounted for.
The documented interview, dated 9/30/25, with RN 2, conducted by the ADNS and DNS, documented by the ADNS, and included in the investigative file into Resident C's, D's, E's, and F's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, On Tuesday September 30th 2025 the DON [Director of Nursing, also known as DNS] spoke with [name of title of RN 2] regarding Fentanyl patches narcotic count error flowsheet, [name of RN 2] stated that she puts the Fentanyl patches on due to [name and title of LPN 4] is allergic to Fentanyl. DON explained to [name of RN 2] that she needed to take a urine drug test, [Name of RN 2] complied [sic] drug test negative, [name of RN 2] stated that yes she did apply patches but only because the other nurse said that she was allergic to Fentanyl. DON explained to nurse that she is suspended during investigation. [Name of RN 2] then exited the building.
The 9/30/25 documented interview with LPN 4, conducted by the ADNS and DNS, documented by the ADNS, and included in the investigative file into Resident C's D's E's and F's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, On Tuesday September 30, 2025 the DON spoke with [name and title of LPN 4] regarding Fentanyl patches narcotic count errors on flowsheet, [name of LPN 4] stated that she is allergic to Fentanyl and that [name and title of RN 2] puts the patches on the resident, DNS explained to nurse [name of LPN 4] that she needs to take s [sic] drug test [name of LPN 4] stated that she took a Percocet earlier that morning due to back pain.
Urine Drug test was given and was positive for opiods [sic.] DON explained to nurse that she was suspended during investigation [name of LPN 4] then left the building. RN 2, LPN 4, and Pharmacist 6 were unavailable for interviews.
The Controlled Substances: Storage, Documentation, Inventory and Destruction policy was provided by the DNS on 1/29/26 at 11:30 a.m. It indicated, Purpose of Policy: To prevent diversion, improper use and accidents related to controlled substances.
Policy: It is the policy of this facility that all controlled substances will be stored, recorded, accounted for, and destroyed by state regulation.Documentation 1.
When a controlled substance is administered to a resident, it must be recorded in the resident's Medication Administration (MAR) as well as in the resident's Controlled Substances Inventory Record at the time of administration.Inventory of Controlled Substances (Shift to Shift Count.) 6.
The Shift Change Verification of Controlled Substances form and addition/removal logs will be maintained in the facility for 24 months. 7.
The resident's Controlled Substance Record will be scanned into resident documents.
This Citation relates to Intake 2632048. 3.1-25(e)(3)
Facility ID: