Inspection Reports for
Capital Oaks Nursing &Amp; Rehabilitation Center LLC
4100 NORTH BLVD, BATON ROUGE, LA, 70806
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Inspection Report — Mar 26, 2025
Routine CMS
Date: Mar 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, PASARR evaluations, dental services, medical record documentation, and infection control.
Findings
The facility failed to ensure accurate resident assessments, proper PASARR coding and referrals, comprehensive and individualized care plans, a policy for denture loss or damage responsibility, complete and accurate medical record documentation, and proper infection prevention practices during catheter care.
Deficiencies (6)
Failed to ensure resident assessments accurately reflected residents' status, including incorrect coding of insulin injections and PASARR Level II status.
Failed to ensure residents with mental health diagnoses were referred for PASARR Level II evaluations as required.
Failed to develop and implement comprehensive, individualized care plans for residents with diagnoses of diarrhea, PASARR Level II, and refusal of monthly weights.
Failed to have a policy identifying circumstances when loss or damage of dentures was the facility's responsibility.
Failed to maintain complete and accurate medical records, including documentation of wound care and enteral feeding administration.
Failed to maintain an infection prevention and control program, specifically failing to ensure proper hand hygiene and glove use during catheter care.
Report Facts
Residents reviewed for PASARR: 8
Residents with PASARR coding errors: 4
Residents not referred for PASARR Level II: 2
Residents reviewed for care plans: 25
Residents with care plan deficiencies: 3
Residents affected by denture policy deficiency: 112
Residents reviewed for documentation accuracy: 25
Residents with documentation deficiencies: 4
Dates with undocumented wound care: 14
Dates with undocumented wound care: 11
Dates with undocumented wound care: 7
Dates with undocumented enteral feeding: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S16 LPN | Licensed Practical Nurse | Confirmed Resident #42 did not have diabetes or receive insulin injections |
| S5 CCC | Care Coordinator | Confirmed PASARR coding errors and care plan deficiencies for multiple residents |
| S2 DON | Director of Nursing | Confirmed expectations for accurate coding, care planning, and infection control practices |
| S4 CCC | Care Coordinator | Verified PASARR Level II status for residents #9, #44, #55 |
| S3 SS | Social Services Staff | Responsible for submitting Resident Review Forms to OBH; confirmed failures to resubmit |
| S12 LPN | Licensed Practical Nurse | Confirmed diagnosis and medication administration for Resident #40 and documentation issues for Resident #89 |
| S6 RN | Registered Nurse | Confirmed wound care treatments were performed but not documented for Residents #9 and #22 |
| S7 RN | Registered Nurse | Confirmed wound care treatments were performed but not documented for Residents #9 and #22 |
| S8 RN | Registered Nurse | Confirmed wound care treatments were performed but not documented for Residents #9 and #53 |
| S9 RN | Registered Nurse | Confirmed wound care treatments were performed but not documented for Resident #9 |
| S10 WC | Wound Care Nurse | Confirmed wound care treatments were performed but not documented for Residents #9 and #53 |
| S11 CNA | Certified Nursing Assistant | Observed failing to perform hand hygiene and glove change during catheter care for Resident #55 |
| S1 ADM | Administrator | Confirmed lack of policy regarding denture loss or damage responsibility |
Inspection Report — Feb 7, 2025
Complaint Investigation CMS
Date: Feb 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to report a resident's fall, resulting in delayed treatment of a femur fracture and inadequate pain management for a cognitively impaired resident.
Complaint Details
The complaint investigation focused on Resident #1, who fell during transfer on 01/02/2025 but the fall was not reported by staff until after the resident was diagnosed with a femur fracture on 01/03/2025. The facility failed to report the neglect allegation to the Administrator and law enforcement within 2 hours as required. The allegation was unsubstantiated but the failure to report was cited.
Findings
The facility failed to notify the physician of a resident's fall and new onset pain, resulting in delayed diagnosis and treatment of a displaced comminuted intertrochanteric femur fracture. Staff did not report the fall or pain timely, leading to an Immediate Jeopardy situation. The facility implemented corrective actions and training prior to survey exit.
Deficiencies (4)
Failure to notify physician of resident's fall and new onset pain, resulting in delayed treatment of femur fracture.
Failure to ensure resident's right to be free from neglect when CNA staff did not report a fall resulting in a femur fracture.
Failure to timely report alleged neglect to Administrator and law enforcement within mandated timeframe.
Failure to provide appropriate pain management and assessment for cognitively impaired resident after fall.
Report Facts
Date of fall: Jan 2, 2025
Date of fracture diagnosis: Jan 3, 2025
Morphine dose: 4
Date of surgical repair: Jan 4, 2025
Date Immediate Jeopardy removed: Feb 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7CNA | Certified Nursing Assistant | Failed to report Resident #1 fall and pain complaints |
| S4LPN | Licensed Practical Nurse | Received pain complaint but did not report fall; assessed Resident #1 on 01/03/2025 |
| S1ADM | Administrator | Notified of Immediate Jeopardy; confirmed failure to report fall and neglect |
| S3RN | Registered Nurse | Notified of pain complaint; confirmed Resident #1 cognitive impairment |
| S2DON | Director of Nursing | Confirmed not aware of fall until 01/30/2025; considered failure to report neglect |
| S13NP | Nurse Practitioner | Not notified of fall or pain complaints until 01/03/2025 |
Inspection Report — Feb 20, 2024
Complaint Investigation CMS
Date: Feb 20, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding the facility's failure to maintain a safe, clean, and comfortable environment, protect residents from physical abuse, and ensure professional standards of care including medication administration and personal grooming.
Complaint Details
The complaint investigation was substantiated regarding physical abuse of Resident #85 by Resident #22 on 02/12/2024. The facility implemented corrective actions including separating the residents, staff in-service training on abuse and aggressive resident management, daily behavioral check-ins, and quality assurance monitoring. The abuse incident was confirmed by multiple staff interviews and documentation.
Findings
The facility failed to maintain a safe and sanitary environment in 7 resident rooms, failed to protect a resident from physical abuse by another resident resulting in actual harm, and failed to meet professional standards in medication administration and personal care. Corrective actions and staff training were implemented during the investigation.
Deficiencies (5)
Floors were missing planks, stained, or sticky in multiple rooms; bathrooms had missing cabinet doors, non-functioning light bulbs, and cracked toilet seats; closet doors were unstable; toilets made loud noises; bathroom sink handles leaked; bed handrails were loose; tubs were dirty.
Resident-to-resident physical abuse occurred when Resident #22 pulled Resident #85 from bed and punched her in the head and face, causing psychosocial harm.
Failure to obtain accuchecks and administer insulin before meals as ordered for Resident #47.
Nursing staff inaccurately documented trimming of fingernails for Resident #74, who had long fingernails and requested trimming.
Medication errors including omission of Voltaren gel for Resident #34 and insulin administered after meals instead of before for Resident #47.
Report Facts
Licensed beds: 123
Residents reviewed for abuse: 32
Residents affected by abuse: 1
Residents reviewed for insulin administration: 3
Residents reviewed for ADLs: 3
Medication administration opportunities observed: 27
Medication errors: 2
Medication error rate: 7.41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S10LPN | Licensed Practical Nurse | First staff to intervene during resident-to-resident physical abuse incident |
| S1ADM | Administrator | Confirmed abuse incident and corrective actions |
| S2DON | Director of Nursing | Confirmed medication errors and staff in-service training |
| S3SSD | Social Services Director | Conducted behavioral check-ins post-abuse incident |
| S7LPN | Licensed Practical Nurse | Responsible for fingernail care documentation, admitted not trimming nails |
| S9LPN | Licensed Practical Nurse | Administered insulin after meals instead of before as ordered |
| S8LPN | Licensed Practical Nurse | Did not administer Voltaren gel as ordered |
Inspection Report — Feb 17, 2023
Complaint Investigation CMS
Date: Feb 17, 2023
Visit Reason
The inspection was conducted to investigate complaints related to inconsistent documentation of a resident's code status, failure to timely report alleged staff-to-resident physical abuse, and inadequate supervision leading to a resident elopement incident.
Complaint Details
The complaint investigation included review of Resident #82's inconsistent code status documentation, Resident #24's abuse allegation reporting delay, and Resident #47's elopement incident. The abuse allegation was substantiated as the facility failed to report within the required timeframe. The elopement incident was substantiated and resulted in immediate jeopardy.
Findings
The facility failed to ensure consistent documentation of Resident #82's code status, failed to report an alleged abuse incident involving Resident #24 within the required 2-hour timeframe, and failed to provide adequate supervision for Resident #47, who eloped from the facility resulting in immediate jeopardy to resident health and safety. The facility implemented corrective actions including staff in-service training, monitoring, and updated policies.
Deficiencies (3)
Failed to ensure all medical records regarding Resident #82's code status consistently reflected the resident's wishes, with conflicting code status documented as DNR and full code.
Failed to timely report alleged staff-to-resident physical abuse involving Resident #24 within 2 hours as required by state law.
Failed to ensure adequate supervision and monitoring for Resident #47, an elopement risk, resulting in immediate jeopardy when the resident wandered off the facility grounds and was found 1.7 miles away.
Report Facts
Residents reviewed for advanced directives: 32
Residents reviewed for abuse: 5
Residents assessed as elopement risk: 4
BIMS score: 15
BIMS score: 3
Time resident #47 was missing: 7.25
Distance resident #47 was found from facility: 1.7
Timeframe for abuse reporting: 2
Frequency of visual checks ordered: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5LPN | Licensed Practical Nurse | Interviewed regarding Resident #82's code status discrepancy. |
| S8MRC | Medical Records Coordinator | Interviewed regarding Resident #82's code status documentation. |
| S3ADON | Assistant Director of Nursing | Responsible for transferring code status from physical chart to electronic medical record for Resident #82. |
| S2DON | Director of Nursing | Verified code status discrepancy for Resident #82 and involved in abuse reporting and elopement incident response. |
| S4LPN | Licensed Practical Nurse | Reported abuse allegation involving Resident #24 and involved in elopement incident investigation. |
| S1ADM | Administrator | Received abuse report and managed elopement incident response. |
| S10CNA | Certified Nursing Assistant | Took Resident #47 outside for Mardi Gras parade and responsible for ensuring resident's safe return. |
| S6LPN | Licensed Practical Nurse | Resident #47's nurse on day of elopement; noticed resident missing during medication pass. |
| S7LPN | Licensed Practical Nurse | Notified Director of Nursing of Resident #47 missing and participated in search. |
| S11CNA | Certified Nursing Assistant | Witnessed events on day of elopement and confirmed Resident #47 should not be outside unsupervised. |
| S12SocS | Social Services | Observed parade and commented on Resident #47's usual behavior and missing status. |
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