Capitol House Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 11546 Florida Blvd, Baton Rouge, Louisiana 70815
- CMS Provider Number
- 195476
- Inspections on file
- 31
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Capitol House Nursing And Rehab Center during CMS and state inspections, most recent first.
Surveyors found that kitchen and dining areas had rusty, dirty ceiling vent coverings and multiple water-stained ceiling tiles. Staff confirmed the unsanitary conditions, lack of recent cleaning, and failure to replace or properly maintain these surfaces, potentially affecting 64 residents receiving meals from the kitchen.
A resident who expired in the facility did not have a required discharge MDS assessment completed or transmitted within the specified timeframe. Staff interviews and record review confirmed the omission, which was not in accordance with facility policy.
A resident receiving IV antibiotics via a Midline device did not have physician orders or documentation for daily assessment or flushing of the vascular access, as required by professional standards. Nursing staff relied on prior knowledge of device placement rather than current assessment, and the necessary maintenance orders and documentation were not obtained or recorded.
Nursing staff did not accurately document a resident's bed baths in the ADL flowsheet, despite the resident being dependent on staff for bathing and scheduled to receive daily baths. Interviews confirmed that the baths were given but not recorded, and nursing leadership verified the documentation was incomplete.
A resident receiving hospice care did not have required hospice nurse visit notes or progress notes in their clinical binder, as confirmed by multiple staff interviews. The facility's policy requires such documentation, but it was not maintained, potentially affecting all residents receiving hospice services.
A resident was transferred to a hospital for treatment, but the facility did not provide the required written notification to the State's LTC Ombudsman. Review of records and interviews confirmed that the transfer was not documented in the Emergency Transfer Log and that no written notice was sent, as mandated by facility policy.
Two residents did not receive care in accordance with their documented needs and preferences: one was not care planned for a daily bed bath despite expressing this preference, and another did not have a required soft mitt or splint in place on her right hand as ordered to prevent tube pulling. Staff interviews and record reviews confirmed these omissions, which were inconsistent with facility policy and physician orders.
A resident with severe cognitive impairment and a history of pressure ulcers, who was at high risk for new ulcers, was observed multiple times with the air mattress pump turned off, despite physician orders and care plan interventions requiring its use. Facility staff, including an LPN and the DON, confirmed the pump should have been on at all times to provide necessary pressure relief.
A resident with an indwelling catheter received incontinence and catheter care from an LPN who failed to follow infection control protocols, including not changing gloves or performing hand hygiene between contaminated and clean tasks, handling clean linens with soiled gloves, and placing soiled washcloths on the floor. The LPN and DON confirmed these actions did not comply with facility policies.
The facility failed to maintain clean and well-maintained A/C window units in resident rooms, leading to a buildup of black substances and dust. A resident expressed concerns about potential allergy exacerbation due to the unclean units. Maintenance logs indicated that scheduled cleaning and maintenance were not performed as required, which was confirmed by facility staff.
The facility failed to store food in accordance with professional standards for food service safety, as observed with improperly stored soy sauce and lemon juice, potentially affecting 78 residents.
The facility failed to ensure that a resident, who was severely cognitively impaired and totally dependent on staff for personal care, was treated with respect and dignity. A CNA entered the resident's room and began providing care without explaining the procedures, contrary to the expectations confirmed by the ADON and DON.
The facility failed to ensure a resident's assessment accurately reflected the discharge status. The MDS Discharge Assessment indicated the resident was discharged to a hospital, but nursing notes and interviews confirmed the resident was discharged home.
The facility failed to refer a resident with mental health diagnoses, including Schizophrenia and Anxiety disorder, for a PASRR Level II evaluation as required. Staff confirmed that a Resident Review form should have been submitted but was not.
A facility failed to report an alleged neglect incident involving a resident with larvae exiting from the mouth within the required timeframe. The incident was discovered by an LPN, and although the facility's policy requires immediate reporting, the report was delayed and not submitted to the state agency until several days later.
A resident with a stage 4 pressure ulcer was not turned and repositioned every two hours as required by their care plan. Video surveillance showed no staff entered the room for several hours, and interviews with the facility's administrator and DON confirmed the care plan was not followed.
Unsanitary Kitchen Conditions Due to Rusty Vents and Stained Ceiling Tiles
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen and adjacent dining areas. Specifically, large ceiling vent coverings above the serving steam table and in the dishwashing room were found to be rusty, dirty, and covered with flakey black debris. Additionally, six ceiling tiles in the main kitchen and two in the dining areas were noted to have water stains ranging from baseball to softball size. These unsanitary conditions were confirmed by staff during interviews, who acknowledged the presence of rust, debris, and water stains, and admitted that the areas had not been properly cleaned or replaced. Staff interviews revealed a lack of knowledge regarding the last time the vents and ceiling tiles were cleaned, and it was confirmed that the maintenance staff was responsible for their upkeep. The maintenance staff member admitted to painting over a vent cover instead of replacing it and acknowledged that both the tiles and vent coverings should have been maintained in a sanitary condition. The administrator also confirmed awareness of the unsanitary conditions and agreed that the necessary replacements had not been made. The deficiency had the potential to affect 64 residents who were served meals from the kitchen.
Failure to Complete and Transmit Discharge Assessment Following Resident Death
Penalty
Summary
The facility failed to complete and transmit a discharge assessment for a resident who expired in the facility. According to the facility's policy, a discharge (death) assessment must be completed no later than seven days after a resident's death and transmitted to the designated CMS system within fourteen days of completion. Record review showed that the resident was admitted and subsequently pronounced deceased in the facility, but no discharge MDS assessment was completed. Interviews with facility staff confirmed that the required discharge assessment was not completed or transmitted as required by policy.
Failure to Ensure Proper IV Therapy Protocols and Documentation
Penalty
Summary
The facility failed to administer parenteral fluids in accordance with professional standards of practice for a resident who required IV therapy. Specifically, there was no documented physician order for daily assessment, dressing changes, or a flushing schedule for the resident's Midline venous access device, despite the resident receiving IV antibiotics. Review of the Medication Administration Record (MAR) also showed no evidence of daily assessment or flushing documentation for the Midline device. During observation, a nurse flushed the Midline device prior to medication administration but based the assessment of patency on having witnessed the device's insertion the previous day, rather than on current clinical assessment or documented protocol. The Director of Nursing confirmed that appropriate orders and documentation for Midline maintenance were missing and that the nurse should have notified the practitioner for the necessary orders and documented the flushes on the MAR.
Failure to Accurately Document Resident Bathing in ADL Records
Penalty
Summary
Nursing staff failed to maintain accurate and complete documentation of a resident's activities of daily living (ADL), specifically regarding bathing. The resident, who was dependent on staff for bathing and preferred daily bed baths, was scheduled to receive a bath Monday through Saturday according to the CNA assignment sheet. However, review of the ADL flowsheet revealed missing documentation for three specific dates, and there was no evidence in the nurses' notes that the resident refused baths on those days. Interviews with the assigned CNAs confirmed that bed baths were provided on the dates in question, but the staff admitted they did not document these baths as required. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) reviewed the records and confirmed the lack of documentation for the resident's baths on the specified dates, acknowledging that the records were not maintained in accordance with accepted professional standards.
Failure to Maintain Hospice Nurse Visit Documentation
Penalty
Summary
The facility failed to maintain a system to ensure that a hospice resident's clinical binder contained required documentation of hospice nurse visit notes. Specifically, a review of a resident's clinical record and hospice binder showed that, although the resident was admitted to hospice care and had an active certification period, there were no hospice nurse visit notes or progress notes present in the binder. This was confirmed through interviews with the hospice liaison, an LPN, the hospice nurse, and the Director of Nursing, all of whom acknowledged the absence of the required documentation in the resident's hospice binder. The facility's policy requires that hospice services be provided or arranged to protect residents' rights, including maintaining appropriate documentation. Despite this policy, the hospice nurse confirmed that weekly assessment documentation had not been placed in the resident's binder, and other staff confirmed that hospice progress notes should have been updated and kept in the binder. This deficiency had the potential to affect any resident receiving hospice services in the facility.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide written notification to the State's Long-Term Care Ombudsman regarding the transfer of a resident to a local hospital. According to the facility's own Transfer and Discharge policy, evidence of such notification is required whenever a resident is transferred or discharged to a bed outside the certified facility. Record review showed that the resident was admitted to the facility and later transferred to a hospital for treatment, as documented in the nurse's notes. However, the Emergency Transfer Log did not include documentation of this transfer, and the facility administrator confirmed that no written notice was sent to the Ombudsman as required by policy.
Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, resulting in unmet needs. For one resident, who was cognitively intact and dependent on staff for bathing due to a cerebrovascular accident, there was no documentation of his stated preference for a daily bed bath. Although the resident and several CNAs confirmed his preference, this information was not reflected in his care plan, ADL flowsheet, or CNA assignment sheet. Staff who were not regularly assigned to him were unaware of his preference, as it was not documented anywhere accessible to them. For another resident with severe cognitive impairment and total dependence on staff for self-care, the care plan and physician's orders required a soft mitt or splint to be in place on her right hand at all times to prevent her from pulling on medical tubing. Multiple observations throughout the day revealed that neither the soft mitt nor the splint was in place on her right hand. Staff interviews confirmed that the resident should have had one of these devices in place at all times, as per the physician's orders and care plan, but this was not being followed. These deficiencies were identified through observations, interviews, and record reviews, and were found to be inconsistent with the facility's own care planning policy, which requires care plans to be based on resident assessments, goals, and preferences, and to be implemented in accordance with physician orders.
Failure to Ensure Air Mattress Function for High-Risk Resident
Penalty
Summary
A resident with a history of pressure ulcers, chronic respiratory failure, anoxic brain damage, muscle wasting, and atrophy was identified as being at high risk for pressure ulcer development, with a Braden Scale score of 11. The resident was dependent on staff for turning and repositioning and had a physician order and care plan intervention for a low air loss mattress to be used as a pressure-distributing support surface. Despite these orders and interventions, multiple observations over two days revealed that the air mattress pump was not turned on while the resident was in bed, meaning the mattress was not providing the intended alternating pressure. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the air mattress pump should have been on at all times for this resident, as it was a key intervention to prevent further pressure ulcer development. The failure to ensure the air mattress was properly implemented and functioning as ordered and care planned constituted a lack of care consistent with professional standards of practice for a resident at high risk for pressure ulcers.
Failure to Follow Infection Control Protocols During Incontinence and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper infection control practices during and after incontinence care for one resident with an indwelling catheter. During observation, an LPN performed incontinence and catheter care without adhering to hand hygiene protocols, including not changing gloves or performing hand hygiene between contaminated and clean tasks. The LPN used soiled gloves to handle clean linens, touched the resident's clean areas, and exited the resident's room without sanitizing hands. Additionally, soiled washcloths were placed on the floor instead of in the designated dirty linen basin, and the LPN failed to wipe away from the catheter tubing and vaginal area as required by facility policy. Interviews with the LPN and the Director of Nursing confirmed that the observed practices did not align with facility policies for catheter care, hand hygiene, and handling of soiled linens. The LPN acknowledged not changing gloves or performing hand hygiene at appropriate times, placing soiled linens on the floor, and not following proper wiping technique. The Director of Nursing confirmed that staff are expected to change gloves when moving from contaminated to clean areas, sanitize hands between glove changes, and properly dispose of soiled linens.
Failure to Maintain Clean A/C Units in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by the lack of maintenance and cleaning of A/C window units in four residents' rooms. Observations revealed that the A/C units had a buildup of black substances, which appeared to be mold, and gray dust on the front panel grills. These conditions were confirmed by both the residents and facility staff during interviews and observations. The facility's maintenance logs showed that the A/C units were due for cleaning and filter replacement, but these tasks were not completed as scheduled. Resident #R1, who was cognitively intact with a BIMs score of 15, expressed concerns about the state of her A/C unit, noting that it could exacerbate her allergy symptoms. The maintenance staff, S2MnD, acknowledged the oversight, stating that the units were supposed to be serviced on specific dates but were not. The facility administrator, S1ADM, also confirmed the presence of black spots on the units and acknowledged that they were overdue for cleaning and maintenance.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, potentially affecting 78 residents who were served meals from the kitchen. During an initial tour of the kitchen, it was observed that a half-empty gallon bottle of soy sauce and a half-empty quart bottle of lemon juice were stored on a shelf instead of being refrigerated, despite the manufacturer's labels indicating they should be refrigerated after opening. The Dietary Manager confirmed that these items should have been refrigerated upon opening but were not. The Administrator also stated that she expected all opened food items requiring refrigeration to be stored in the refrigerator.
Failure to Ensure Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure that each resident was treated with respect and dignity, specifically in the case of Resident #82. Resident #82, who was admitted with diagnoses including Cerebral Infarction, Tracheostomy, and a need for assistance with personal care, was assessed as severely cognitively impaired with a BIMS of 0. The resident was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. On one occasion, a CNA entered Resident #82's room, pulled the curtain, and began turning the resident without explaining the care to be provided. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that staff are expected to greet residents and explain the care to be provided, which did not occur in this instance.
Inaccurate Discharge Assessment
Penalty
Summary
The facility failed to ensure a resident's assessment accurately reflected the discharge status. Specifically, for Resident #97, the MDS Discharge Assessment indicated that the resident was discharged to a general hospital. However, a review of the nursing notes revealed that the resident was actually discharged home, as evidenced by the resident's son loading up all belongings and assisting the resident into a private car. Interviews with S5MDS and S2DON confirmed that the MDS Discharge Assessment was not coded correctly and should have indicated that the resident was discharged home.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required. Resident #4 was admitted with diagnoses including Schizophrenia, Anxiety disorder, Schizoaffective Disorder, and Unspecified Psychosis. Despite these diagnoses, there was no documentation of a Level II PASRR evaluation. Interviews with staff confirmed that a Resident Review form should have been submitted for evaluation and determination for Level II services but was not.
Failure to Timely Report Alleged Neglect Incident
Penalty
Summary
The facility failed to report an alleged violation involving neglect within the required timeframe. The incident involved a resident who was admitted with a diagnosis that included attention to a tracheostomy. On May 17, 2024, at 4:00 a.m., a Licensed Practical Nurse (LPN) was summoned to the resident's room by the charge nurse. Upon arrival, the resident was found stable but with a large amount of larvae exiting from the mouth area. An ambulance was called to transport the resident out of the facility. The facility's policy mandates that alleged violations must be reported immediately to the administrator and within 24 hours to the state agency. However, the investigative report for this incident was not entered into the system until May 20, 2024, at 12:18 p.m., which was beyond the 24-hour reporting requirement. The administrator confirmed during an interview that the incident was not reported within the required timeframe, acknowledging the delay in reporting to the state agency.
Failure to Implement Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to implement the care plan for a resident who was supposed to be turned and repositioned every two hours as per physician orders. The resident, who was admitted with an unspecified open wound of the lower back and pelvis, had a care plan intervention requiring repositioning every two hours due to a stage 4 pressure ulcer on the right shoulder. However, video surveillance revealed that no staff entered the resident's room from the evening of one day until early morning the next day, resulting in a failure to adhere to the care plan. Interviews with the facility's administrator and director of nursing confirmed the lapse in care. Both acknowledged that the resident's care plan was not followed, as neither a nurse nor a CNA entered the room during the specified time frame to perform the required repositioning. This oversight was verified through video evidence and staff interviews, highlighting a significant deficiency in the facility's adherence to prescribed care protocols for pressure ulcer management.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
