Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Capitol House Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with depression, schizophrenia, and panic disorder received Buspirone for anxiety and Remeron for depression and insomnia, but the record contained no documented monitoring for effectiveness or side effects. The care plan called for shift-by-shift monitoring, yet the MAR and nurses' notes had no related entries. Staff interviews confirmed the psychotropic monitoring task was not properly attached and that no documentation of monitoring was found.
A resident with functional quadriplegia, severe cognitive impairment, ventilator dependence, and total dependence for mobility and ADLs did not have a care plan that identified the needed level and number of staff for safe bed mobility and in-bed ADL care. Staff left the decision to the assigned CNA, who was providing care alone when the resident fell off the bed during turning. Interviews confirmed the resident required at least 2-person assistance, but this was not documented in the care plan.
Enteral feeding orders were not verified, administered, or documented accurately for a resident with CVA, dysphagia, and PEG status. An LPN initialed bolus and continuous feeding orders on the MAR, but the resident was observed receiving continuous Glucerna 1.5 at 65 mL/hr while the LPN stated she did not give the ordered bolus feedings and believed the tube feeding was ordered 24/7; the DON confirmed the resident was ordered bolus feedings during the day and continuous feeding overnight.
Failure to assess needed staff assistance for safe in-bed care: A resident with functional quadriplegia, severe cognitive impairment, ventilator dependence, and a history of falls was totally dependent for mobility and ADLs, yet the facility had no documented assessment for the number of staff needed for safe bed mobility and in-bed care. Staff said the CNA assigned to the resident decided on the amount of help needed, and the resident fell from the bed while a CNA was turning her alone for care.
A resident with a PEG tube, dysphagia, and a history of cerebral infarction was ordered to receive bolus Glucerna 1.5 feedings during the day and continuous feedings overnight. During observation, the resident was receiving only continuous feeding, and an LPN confirmed she did not give the ordered daytime bolus feedings because she believed the order was for continuous feeding 24/7. The DON confirmed the resident should have received the enteral feedings as ordered by the MD.
Expired multi-dose insulin was found on Cart 1 during survey observation. An LPN confirmed two opened Humulin R vials and one opened Novolin R vial had been kept beyond the allowed open-date timeframe, and the DON confirmed the vials were expired per manufacturer guidance and should not have been available for resident administration.
Inaccurate wound care documentation was found for a resident with a Stage 4 pressure ulcer of the left heel. The chart showed a physician order and TAR for a right heel wound, even though no right heel ulcer was documented and staff were observed providing wound care to the left heel. The wound care nurse and DON both confirmed the order and documentation were entered incorrectly.
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.
Missing Monitoring Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free of unnecessary medications by not documenting monitoring for side effects and effectiveness of psychotropic medications. Resident #10 was admitted with diagnoses including unspecified depression, schizophrenia, and panic disorder, and was receiving Buspirone HCl 5 mg three times daily for anxiety and Remeron 30 mg daily for depression and insomnia. Review of the resident's physician orders, care plan, MAR, and nurses' notes showed no documented monitoring for effectiveness or side effects of the psychotropic medications. The care plan directed staff to monitor anti-anxiety and antidepressant medications every shift for side effects and effectiveness, but the record contained no corresponding documentation in the MAR or nurses' notes during the reviewed period. Staff interviews confirmed the lack of documentation. An LPN stated the computer prompts nurses to document monitoring of abnormal side effects and behaviors and confirmed she could not find documentation for Resident #10. The staff member responsible for entering orders stated the psychotropic monitoring task should have been attached to the medications but was not, and the DON confirmed there was no documented monitoring by nurses and that there should have been.
Failure to Specify Required Staff Assistance in Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, resident-centered care plan that identified the appropriate level and number of staff needed for safe bed mobility and ADL care performed while the resident was in bed. Resident #101 was admitted with diagnoses including functional quadriplegia, debility, acute and chronic respiratory failure with hypercapnia, tracheostomy status, dependence on a ventilator, and a history of repeated falls. Her record showed she weighed 263 pounds, had a BIMS score of 04 indicating severe cognitive impairment, had bilateral upper and lower extremity impairment, and was totally dependent on staff for all mobility, ADLs, and care needs. Review of the resident’s physician orders, therapy plans of care, and care plan revealed no documented evidence identifying the required level and number of staff assistance for safe bed mobility and ADL care while in bed. Her care plan included focus areas for ADL self-care deficit related to anoxic brain damage and impaired mobility, and risk for falls related to impaired mobility, but did not specify the staffing assistance needed for care in bed. Staff interviews confirmed that the facility did not require this information to be included in the care plan and instead left it up to the CNA assigned to the resident to determine whether help was needed. On 05/30/2026, an incident report documented that the resident fell off her bed while a CNA was turning her during resident care. The CNA stated he was changing the resident by himself when her weight shifted and he was unable to prevent her from falling to the floor. The LPN, PTA, MDS nurse, ADON, and DON all confirmed the resident would require at least 2-person assistance for safe bed mobility and ADL care while in bed, and confirmed that this level of assistance was not included in the resident’s care plan.
Enteral Feeding Orders Not Verified, Administered, or Documented Accurately
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality by not ensuring nursing staff verified, accurately administered, and accurately documented enteral feedings for one resident. The facility policy stated feeding tubes are to be used according to physician or nurse practitioner orders, including the kind of feeding, caloric value, volume, duration, mechanism of administration, and frequency of flush, and that documentation in the medical record must be factual and accurate. Resident #7 had diagnoses including cerebral infarction, dysphagia, and gastrostomy status, and had physician orders for Glucerna 1.5 bolus feedings of 300 mL via PEG at 8:00 a.m., 12:00 p.m., and 4:00 p.m., along with continuous Glucerna 1.5 at 65 mL/hr via PEG from 6:00 p.m. to 6:00 a.m. The MAR showed S5LPN initialed the enteral feeding orders for the 12:00 p.m. and 4:00 p.m. bolus feedings and for the continuous feeding during day and evening shifts on 07/19/2026. However, an observation at 12:08 p.m. showed the resident receiving Glucerna 1.5 continuously at 65 mL/hr via pump. In interview, S5LPN confirmed she was assigned to the resident from 6:00 a.m. to 6:00 p.m., stated she did not administer any bolus feedings that day, and said she thought the resident was ordered continuous tube feeding 24/7. She confirmed the resident should have received tube feeding as ordered and that she should have verified the order, accurately administered the feeding, and accurately documented it. The DON also confirmed the resident was ordered bolus feedings during the day and continuous feeding overnight, and that the nurse should have reviewed, administered, and accurately documented the enteral feeding as ordered.
Failure to assess needed staff assistance for safe in-bed care
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents by not ensuring that each resident was assessed for the appropriate level and number of staff needed for safe bed mobility and ADL care performed while in bed. The deficiency involved one resident reviewed for ADLs, who was admitted with diagnoses including functional quadriplegia, debility, acute and chronic respiratory failure with hypercapnia, tracheostomy status, dependence on a ventilator, and a history of repeated falls. The resident weighed 263 pounds, had a BIMS score of 04 indicating severe cognitive impairment, was totally dependent on staff for all mobility, ADLs, and care needs, and had a fall risk score indicating high fall risk. The resident’s clinical record, therapy documentation, care plan, and physician orders contained no documented evidence that she was assessed to determine the appropriate level and number of staff assistance required for safe mobility, ADLs, and care needs performed in bed. The facility’s ADL policy stated that a resident unable to carry out ADLs would receive necessary services to maintain good personal hygiene, and the turning and repositioning policy stated that the appropriate number of staff should be used to perform tasks safely. However, staff interviews confirmed that the facility did not assess the level of assistance needed for these tasks and instead left it to the CNA assigned to the resident to decide how much help was required. An incident report documented that the resident fell off her bed while a CNA was turning her for resident care. The CNA stated he was changing the resident by himself when her weight shifted as he rolled her over and he was unable to prevent her from falling to the floor. Interviews with nursing and therapy staff confirmed the resident was non-verbal, unresponsive, unable to assist with care, and that in their opinion she required at least 2-person assistance, with one CNA stating she would not feel safe providing care with fewer than 3 people. The DON confirmed the facility did not ensure each resident was assessed for the level of staff assistance required to safely complete bed mobility and in-bed ADL care.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
The facility failed to ensure a resident with a feeding tube received enteral feedings as ordered by the physician. Resident #7 had diagnoses including cerebral infarction, dysphagia, and gastrostomy status, and his record showed he received nutrition and hydration through an enteral feeding tube. His physician orders included Glucerna 1.5 bolus feedings of 300 mL via PEG three times daily at 8:00 a.m., 12:00 p.m., and 4:00 p.m., as well as continuous Glucerna 1.5 at 65 mL/hr via PEG from 6:00 p.m. to 6:00 a.m. During observation, Resident #7 was seen lying in bed with Glucerna 1.5 infusing continuously at 65 mL/hr via pump. The assigned LPN confirmed she worked with the resident during the day shift and stated she did not administer any bolus enteral feedings that day because she believed the resident was ordered to receive continuous feedings 24/7. She acknowledged the resident should have received enteral feedings as ordered. The DON also confirmed the resident was ordered to receive bolus feedings during the day and continuous feedings overnight, and stated the enteral feedings should have been administered as ordered by the physician.
Expired Multi-Dose Insulin Left on Medication Cart
Penalty
Summary
Drugs and biologicals used in the facility were not stored in accordance with currently accepted professional principles because medication carts contained expired multi-dose insulin available for resident use. Review of the facility policy on multiple-dose vials stated that once a vial has been opened or accessed, it should be dated and discarded within 28 days unless the manufacturer specifies a different timeframe. Manufacturer guidance reviewed for Humulin R stated it should not be used past the expiration date on the label or 31 days after first use, and Novolin R guidance stated opened multi-dose vials must be discarded 42 days after the first puncture. On observation of Cart 1, surveyors found two opened and punctured multi-dose vials of Humulin R and one opened and punctured multi-dose vial of Novolin R on the medication cart. The vials were dated beyond the timeframe confirmed by staff during interviews. An LPN stated multi-dose insulin should only be available on the medication cart for a maximum of 30 days after the labeled open date, and the DON confirmed the vials were expired per manufacturer guidelines and should not have been available for resident administration.
Inaccurate Wound Care Documentation
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for one resident with a pressure ulcer. Resident #5 was admitted with diagnoses that included a Stage 4 pressure ulcer of the left heel, but the clinical record contained a physician order entered for a right heel pressure ulcer instead. The order directed wound cleanser, pat dry, betadine, and a dry dressing every other day until resolved, and the treatment administration record documented that this right heel treatment was performed on multiple dates in July 2026. However, wound care assessments contained no documented evidence of a right heel pressure ulcer, and an observation of wound care showed staff providing treatment to the resident's left heel pressure ulcer. During interview, the wound care staff member confirmed the order had been entered incorrectly for the right heel and stated it should have been for the left heel. The Director of Nursing also reviewed the record and confirmed the resident had a left heel pressure ulcer and that the wound care orders and documentation were not accurately recorded.
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.
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Illustrative
What surveyors actually found near you
We read the 131 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Baton Rouge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Guest House Care Center | 0.9 mi | ★★★★★ | 7 | 0 |
| Flannery Oaks Guest House | 1.3 mi | ★★★★★ | 0 | 0 |
| The Woodleigh Of Baton Rouge | 1.8 mi | ★★★★★ | 0 | 0 |
| Pines Retirement Center Of Baton Rouge | 2 mi | ★★★★★ | 0 | 0 |
| White Oak Post Acute Care | 2.3 mi | — | 21 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.