Capital Oaks Nursing & Rehabilitation Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 4100 North Blvd, Baton Rouge, Louisiana 70806
- CMS Provider Number
- 195635
- Inspections on file
- 18
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Capital Oaks Nursing & Rehabilitation Center Llc during CMS and state inspections, most recent first.
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.
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.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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