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
During the survey process 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.
The Abuse Prohibition, Reporting, and Investigation policy was provided by the ED (Executive Director) on 1/23/26 at 4:31 p.m. It indicated, It is the policy of [name of facility] to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation.Misappropriation of Resident Funds or Property -Deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident' property or money without the resident's consent.
Cross Reference F-F697-
The facility failed to verify placement of 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)
155226 01/29/2026
North Capitol Nursing & Rehabilitation Center 2010 N Capitol Ave Indianapolis, IN 46202
1/29/26 at 11:30 a.m. It indicated, It is the policy of [name of facility] to provide the necessary care
upon the resident's intensity of pain.A plan of care will be written with the initiation of pain
155226 01/29/2026
North Capitol Nursing & Rehabilitation Center 2010 N Capitol Ave Indianapolis, IN 46202
unaccounted for.
The documented interview, dated 9/30/25, with RN 2, conducted by the ADNS and
Tuesday September 30th 2025 the DON [Director of Nursing, also known as DNS] spoke with [name
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)