Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Capital Oaks Nursing & Rehabilitation Center Llc during CMS and state inspections, most recent first.
Ordered nutritional supplements were not provided with meal trays for two residents. One resident with dementia, Alzheimer's disease, and abnormal weight loss had orders for a high-protein, high-calorie shake and a Nutri-Freeze cup, but neither item was on the breakfast tray. Another resident with dementia, adult failure to thrive, and abnormal weight loss had orders for a high-protein, high-calorie shake and a Nutri-Freeze cup with meals, but neither item was on the lunch tray. CNAs confirmed the missing items, and the DON stated supplements ordered with meals should be on the tray as ordered.
The facility failed to ensure accurate resident assessments, leading to errors in documenting insulin injections and PASARR Level II status. A resident was incorrectly coded as receiving insulin despite no diabetes diagnosis, and four residents with serious mental illness were inaccurately documented as not having a PASARR Level II. Staff interviews and record reviews confirmed these discrepancies.
The facility failed to create comprehensive care plans for residents, including one with diarrhea, another with a Level II PASRR, and a resident refusing weight checks. Staff confirmed the absence of individualized care plans for these issues, despite the facility's policy requiring such plans.
The facility lacked a policy to determine responsibility for lost or damaged dentures, as confirmed by the DON and Administrator. This deficiency could impact any of the 112 residents with dentures.
The facility failed to maintain accurate medical records for four residents, leading to deficiencies in documenting wound care and enteral feeding. Several RNs and an LPN confirmed that care was provided but not documented, which was acknowledged as an oversight. The DON reviewed and confirmed the missing documentation, highlighting a deviation from the facility's policy.
The facility failed to submit PASRR Level II evaluations for two residents with new mental health diagnoses. One resident was diagnosed with Schizophrenia and Manic Episode, while another was diagnosed with Delusional Disorders, Psychosis, and Major Depressive Disorder. The necessary documentation was not submitted to the Office of Behavioral Health, despite requests and acknowledgment from the responsible staff member.
A facility failed to maintain proper infection control during catheter care for a resident with a urinary catheter. The CNA did not change gloves or perform hand hygiene after cleaning the resident's genitalia and buttocks before proceeding with catheter care. This was confirmed by the CNA and acknowledged by the DON.
A cognitively impaired resident experienced a fall during a transfer, which was not reported by the CNAs involved. Despite new onset pain and increased need for assistance being observed by multiple staff members, the incident and changes in condition were not communicated to nursing or medical staff. This led to a delay in assessment and treatment, with the resident ultimately being diagnosed with a severe femur fracture requiring surgical intervention.
A resident with severe cognitive impairment experienced a fall during a transfer that was not reported by CNAs to nursing staff. Over the next day, the resident showed new pain and required more assistance, but these changes were not communicated to the physician or addressed promptly. The delay resulted in the discovery of a femur fracture only after further assessment, leading to hospital transfer and surgery. The lack of timely reporting and intervention constituted neglect.
A resident with severe cognitive impairment suffered a fall during a transfer, which was not reported by the CNA involved. Despite multiple complaints of new pain and increased need for assistance, staff failed to conduct a thorough pain assessment or notify the physician. The resident did not receive pain medication until the next day, when an x-ray revealed a displaced femur fracture requiring surgical intervention.
A resident sustained a femur fracture after an unreported fall during a transfer by a CNA. The incident was not disclosed to nursing staff or supervisors, and another CNA who assisted also failed to report the fall. The DON and Administrator only learned of the fall weeks later and did not update the incident report or notify authorities as required, resulting in a failure to meet mandated reporting requirements for suspected neglect.
Ordered Nutritional Supplements Missing From Meal Trays
Penalty
Summary
The facility failed to ensure residents were offered ordered nutritional supplements with meals for 2 of 5 residents reviewed for nutrition. Resident #18 had diagnoses including Dementia, Alzheimer's Disease, and Abnormal Weight Loss, and his quarterly MDS showed a BIMS of 6, indicating severe cognitive impairment. His physician orders included a generic high protein, high calorie health shake with meals and a Nutri-Freeze cup three times a day. During an observation of his breakfast tray and meal ticket, neither the nutritional shake nor the Nutri-Freeze cup was present on the tray, and both the CNA and LPN confirmed the items were missing and should have been included. Resident #96 had diagnoses including Dementia, Adult Failure to Thrive, and Abnormal Weight Loss, and her quarterly MDS showed a BIMS of 15, indicating she was cognitively intact. Her physician orders included a generic high protein, high calorie health shake with meals and a Nutri-Freeze cup with meals, and her care plan addressed altered nutrition and dehydration with high protein shakes three times a day. During an observation of her lunch tray and meal ticket, neither ordered supplement was on the tray. The resident stated she enjoyed the frozen snack and would eat it if it was on her tray, and the CNA confirmed the tray did not have the ordered nutritional shake or Nutri-Freeze Cup and should have. The DON stated that if dietary supplements were ordered with meals, they should be on the resident's tray as ordered.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments, leading to deficiencies in the documentation of insulin injections and PASARR Level II status. For Resident #42, the clinical record inaccurately indicated that the resident received insulin injections for seven days, despite no active diagnosis of Diabetes Mellitus or physician orders for insulin. Interviews with the resident, an LPN, and the CCC confirmed the error, as the resident did not have a history of diabetes or receive insulin injections. Additionally, the facility failed to accurately document the PASARR Level II status for four residents. Residents #9, #44, #53, and #55 were all approved for admission with a Level II PASARR due to serious mental illness or related conditions. However, their MDS assessments incorrectly indicated that they did not have a PASARR Level II. Interviews with the CCC and DON confirmed these discrepancies, acknowledging that the residents should have been coded correctly for having a Level II PASARR. These inaccuracies in resident assessments highlight a failure in the facility's processes to ensure that resident records accurately reflect their medical conditions and required screenings. The errors were confirmed through interviews with staff and a review of the residents' clinical records, indicating a need for improved accuracy in documentation and assessment processes.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive and individualized care plans for several residents, leading to deficiencies in care. One resident with a diagnosis of diarrhea did not have an individualized care plan addressing this condition, despite receiving prescribed anti-diarrhea medications. This oversight was confirmed by the staff responsible for care plans, who acknowledged the absence of a care plan for this diagnosis. Another resident with a Level II PASRR, indicating the need for specialized services due to mental health conditions, also lacked an individualized care plan that included the recommended services. Additionally, a resident with a history of refusing monthly weight checks was not care planned for this behavior, despite a significant weight loss over several months. The staff responsible for weighing residents confirmed the resident's refusal to be weighed and the lack of documentation or care planning for this issue. The Director of Nursing confirmed the expectation that all care plans should be developed and implemented according to each resident's individualized needs.
Lack of Policy on Denture Loss or Damage Responsibility
Penalty
Summary
The facility failed to establish a policy that identifies the circumstances under which the loss or damage of dentures would be the facility's responsibility. This deficiency was identified during a review of the facility's undated policies titled, Oral/Teeth Management and Care: A.M., which did not specify the facility's responsibility in such cases. During interviews, the Director of Nursing (S2DON) and the Administrator (S1ADM) both confirmed the absence of a policy addressing the responsibility for lost or damaged dentures. This oversight had the potential to affect any of the 112 residents residing in the facility who wore dentures.
Deficiencies in Documentation of Wound Care and Enteral Feeding
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents, leading to deficiencies in documentation of wound care and enteral feeding administration. Resident #9, who was admitted with Hidradenitis Suppurativa, had multiple instances where wound care treatments were not documented as completed on specific dates in February and March 2025. Interviews with several registered nurses (RNs) confirmed that the wound care was performed but not documented, which was acknowledged as an oversight. Resident #22, admitted with a traumatic amputation, also had incomplete documentation for wound care and skin assessments on several dates in February and March 2025. The RNs responsible for these tasks confirmed that the care was provided but not recorded, which was a deviation from the facility's documentation policy. Similarly, Resident #53, with chronic venous insufficiency and ulcers, had missing documentation for wound care treatments on specified dates. The wound care coordinator and an RN confirmed the treatments were completed but not documented. Resident #89, who required enteral feeding due to dysphagia following a cerebral infarction, had missing documentation for PEG flushes and feedings on several occasions in February and March 2025. An LPN confirmed that the feedings were administered but not documented. The Director of Nursing (DON) reviewed the records and confirmed the missing documentation for all residents, acknowledging that the treatments and feedings should have been accurately documented upon completion.
Failure to Submit PASRR Level II Evaluations for Residents
Penalty
Summary
The facility failed to ensure that two residents with identified mental health diagnoses were referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. Resident #31 was admitted to the facility and diagnosed with Schizophrenia and Manic Episode. Despite having a temporary PASRR Level II approval that expired, the facility did not resubmit a Resident Review Form after the new diagnosis was made. Interviews with the Office of Behavioral Health (OBH) and the staff member responsible for submitting the forms confirmed that the necessary documentation was not submitted. Similarly, Resident #79 was diagnosed with Delusional Disorders, Psychosis, and Major Depressive Disorder. The facility did not submit a new Resident Review Form following these diagnoses, despite a request from OBH for updated documentation. The staff member responsible for submitting the forms acknowledged that the required documentation was not provided. This oversight resulted in a failure to comply with the PASRR Level II evaluation requirements for both residents.
Inadequate Infection Control During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the area of catheter care for a resident with a urinary catheter. The resident, who was admitted with a diagnosis of a urinary tract infection, was observed receiving catheter care from a CNA. During the procedure, the CNA cleansed the resident's genitalia and then removed bowel movement from the resident's buttocks. However, the CNA did not change gloves or perform hand hygiene before proceeding with catheter care. This lapse in proper infection control practices was confirmed by the CNA during an interview, acknowledging the failure to change gloves and perform hand hygiene as required. The Director of Nursing was informed of the observation and confirmed the CNA's actions were not in compliance with proper infection control protocols.
Failure to Notify Physician and Assess Resident After Fall Results in Delayed Treatment
Penalty
Summary
The facility failed to ensure that a resident's physician was notified of significant changes in the resident's condition following a fall, which required a change in treatment. A cognitively impaired resident with severe dementia, aphasia, and a cognitive communication deficit experienced a fall during a transfer when a CNA was assisting him. The resident was lowered to the ground and struck his left side on the wheelchair. The CNA involved did not report the fall to the nurse or supervisor, and another CNA who assisted in moving the resident from the floor to the wheelchair also failed to report the incident. As a result, the resident was not assessed by a licensed nurse immediately after the fall, contrary to facility policy. Following the fall, the resident began to complain of new onset pain and required increased assistance with transfers, which was not his baseline. Multiple staff members observed these changes, including increased pain during transfers and a decline in mobility, but did not report the fall or the changes in condition to nursing or administrative staff. The LPN who was notified of the pain did not report the new onset of pain to her supervisor or the nurse practitioner, nor did she administer pain medication. The resident's increased need for assistance and pain complaints continued for over 24 hours without appropriate assessment or intervention. It was only after further complaints of pain and a physical assessment by nursing staff that the nurse practitioner was notified, leading to an x-ray that revealed a displaced comminuted intertrochanteric femur fracture. The resident was then transferred to the hospital, where he received pain management and underwent surgical repair. Throughout this period, the failure to report the fall and subsequent changes in the resident's condition resulted in a significant delay in diagnosis and treatment.
Removal Plan
- All residents who were identified as cognitively impaired were assessed to see if they showed any signs or symptoms of pain. A thorough review of each of the cognitively impaired residents fall risk assessment was completed by the Clinical Care Coordinators.
- All staff were trained by the Administrator, DON, or designee to report any observed or verbalized pain or any change of condition immediately to a nurse or an administrative team member. The nurse or an administrative nurse will follow the standing or PRN orders and will follow up with their MD.
- Nursing staff were trained by DON or designee on proper pivot transfers for one-person assist residents. Training emphasized that if a resident is combative, staff should not transfer the resident alone and should seek assistance.
- Staff were educated by administrator, DON, or designee on the corporate policy for identifying and reporting incidents and accidents. The in-service also included the reporting process of when an incident/accident occurs.
- Staff were educated by administrator, DON, or designee that covered definitions and examples of abuse and neglect.
- Nursing Staff were educated on identifying high fall risk residents, using assistive device markers and wall indicators - Falling Star Program.
- All nurses were in-serviced to ensure a proper pain assessment was completed when a resident reports or shows any signs of pain to a staff member.
- Monitoring was implemented to assess and observe one-person pivot transfers conducted by the DON or designee 3 times a week for 6 weeks and monthly thereafter for 3 months.
- Monitoring was implemented to assess resident pain with interviews of a random sample of nurses 3 times a week for 6 weeks and monthly thereafter including a specific section asking residents about pain during transfers.
- Evaluation of staff knowledge, using a questionnaire, on handling incidents and accidents. Random audits conducted on 10 staff members per week for 6 weeks, followed by periodic checks.
- Daily huddles with administrative staff in random facility sections asking nurses and CNAs about any observations of pain or incidents that occurred during their shift. These huddles will be conducted daily for 2 weeks, then monthly thereafter for 3 months.
Failure to Report Fall and Delay in Treatment Leads to Resident Neglect
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to report a fall involving a cognitively impaired resident with severe dementia and expressive aphasia. During a transfer, the resident was lowered to the ground and struck his left side on the wheelchair. The CNA, along with another CNA who assisted in moving the resident back to his wheelchair, did not report the fall to nursing staff or supervisors. The resident did not initially complain of pain or show visible injuries, and the incident was not documented or communicated as required by facility policy. Following the unreported fall, the resident began to exhibit new onset pain and required increased assistance with transfers. Multiple CNAs noted the resident's complaints of pain and changes in his ability to stand and pivot, which were not typical for him. Despite these observations, the pain and decline in status were not reported to the physician or appropriately addressed by nursing staff for over 24 hours. The resident's cognitive impairment limited his ability to communicate the extent of his pain or the effects of the fall. Eventually, nursing staff became aware of the resident's pain and conducted an assessment, which led to an x-ray and the discovery of a displaced comminuted intertrochanteric femur fracture. The resident was subsequently transferred to the hospital, where he received pain management and underwent surgical intervention for the fracture. The failure to report the fall and the delay in assessment and treatment constituted neglect, as the resident did not receive timely and necessary medical care following the incident.
Removal Plan
- All staff were in-serviced on resident pain and change of condition reporting
- Nursing staff were in-serviced on proper transfers
- All staff were in-serviced on abuse and neglect policies including different types of abuse and neglect and how they can occur in the facility and corporate policies identifying, preventing, and reporting abuse or neglect
- In-service conducted on incident and accident reporting including definitions and reinforcement of the need for immediate documentation and notification of supervisory staff
- Daily huddles performed with CNAs and nurses, randomly picking a section of the building and asking if any reported falls or if any issues of abuse/neglect have been reported
- QA monitoring of one person assist transfers and assessment of pain and reporting of falls. An administrative nurse or designee will randomly monitor transfers
- Implementation of a questionnaire regarding abuse and neglect: A questionnaire will be implemented randomly monitoring all staff members of their knowledge of abuse/neglect. Ten staff members will be randomly selected and questioned. The questionnaire will bring up specific types of abuse/neglect and if the staff members know and understand what they are. Random checks will continue to ensure continued compliance
- Incident and accident Questionnaire - A questionnaire will be implemented randomly monitoring staff members for their knowledge of incident and accident reports. The questionnaire gives specific examples of what to do if a resident is on the floor and how to report those instances to administration
Failure to Assess and Manage Pain After Fall in Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with severe dementia and communication deficits experienced a fall during a transfer, in which he struck his left side on a wheelchair. The certified nursing assistant (CNA) involved in the incident did not report the fall to nursing staff or supervisors, and the resident was moved without a licensed nurse first assessing his condition, contrary to facility policy. Following the fall, the resident exhibited new onset pain and required increased assistance with transfers, but these changes were not appropriately assessed or reported to the physician for further intervention. Multiple staff members, including CNAs and LPNs, observed or were informed of the resident's complaints of pain and changes in mobility throughout the day following the fall. Despite these observations and reports, a thorough pain assessment was not conducted, and the resident did not receive any pain medication until the following morning. The resident's pain was only formally assessed after further complaints and visible signs of pain, at which point an x-ray was ordered, revealing a displaced comminuted intertrochanteric femur fracture. The resident, who had a history of muscle wasting, osteoporosis, dementia, Alzheimer's disease, and aphasia, was unable to effectively communicate the extent of his pain due to his cognitive impairment. Staff interviews confirmed that the resident did not normally complain of pain and that his new complaints were not adequately investigated. The failure to assess, report, and treat the resident's pain in a timely manner resulted in a delay in diagnosis and appropriate pain management for a significant injury.
Removal Plan
- All residents who were identified as cognitively impaired were assessed to see if they showed any signs or symptoms of pain. A thorough review of each of the cognitively impaired residents fall risk assessment was completed by the Clinical Care Coordinators.
- All staff were trained by the Administrator, DON, or designee to report any observed or verbalized pain or any change of condition immediately to a nurse or an administrative team member. The nurse or an administrative nurse will follow the standing or PRN orders and will follow up with their MD.
- All nurses were in-serviced to ensure a proper pain assessment was completed when a resident reports or shows any signs of pain to a staff member.
- Monitoring was implemented to assess resident pain with interviews of a random sample of nurses including a specific section asking residents about pain during transfers.
- Daily huddles with administrative staff in random facility sections asking nurses and CNAs about any observations of pain or incidents that occurred during their shift. These huddles will be conducted daily for 2 weeks, then monthly thereafter for 3 months.
Failure to Timely Report Resident Fall and Suspected Neglect
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect was reported immediately to the Administrator and law enforcement within the required timeframe after an incident involving a resident. A resident, who was admitted to the facility and later diagnosed with a left femur fracture, complained of pain in the morning and was subsequently sent to the emergency room after an x-ray confirmed the injury. There was no documented history of recent falls for this resident. However, it was later discovered through interviews that the resident had fallen to the floor during a transfer by a CNA, who did not report the incident to nursing staff or supervisors. Another CNA assisted in moving the resident from the floor to the wheelchair but also failed to report the fall. The Director of Nursing and the Administrator both confirmed that they became aware of the fall weeks after the incident, and no new or revised self-reported incident was submitted to the state agency or law enforcement after learning the true cause of the injury. The Administrator acknowledged that withholding information about a resident's fall, which delayed necessary care, constituted neglect. The facility did not update the original incident report or notify the appropriate authorities as required by regulations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 136 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baton Rouge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mid City Community Nursing And Rehab | 0.1 mi | ★★★★★ | 5 | 0 |
| Sterling Place Healthcare & Rehabilitation Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Baton Rouge General Medical Center, Snf | 0.3 mi | ★★★★★ | 1 | 0 |
| St Clare Manor Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 4 | 0 |
| St James Place Nursing Care Center | 3.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Capital Oaks Nursing & Rehabilitation Center Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.