Inspection Report Summary
The most recent inspection on June 11, 2025, identified deficiencies related to discharge notifications, care planning, pressure ulcer prevention, and infection control practices. Earlier inspections showed a pattern of similar issues including incomplete care plans, pressure ulcer care, infection control lapses, and maintenance concerns such as unsanitary kitchen conditions and unclean A/C units. A substantiated complaint investigation in June 2024 found failures in resident dignity, timely reporting of neglect involving maggots, and implementation of care plans. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s deficiencies have been consistent over time without a clear trend of improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
158% worse than Louisiana average
Louisiana average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
97 residents
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 97
Deficiencies: 4
Date: Jun 11, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, transfer and discharge notifications, care planning, pressure ulcer prevention, and infection control practices.
Findings
The facility was found deficient in notifying the Long-Term Care Ombudsman of resident discharges, developing and implementing comprehensive care plans reflecting resident preferences, ensuring proper pressure ulcer prevention interventions, and maintaining appropriate infection prevention and control practices during incontinence care.
Deficiencies (4)
Failed to notify the State's Long-Term Care Ombudsman in writing of resident discharge for 1 sampled resident.
Failed to develop and implement a comprehensive person-centered care plan meeting the needs of 2 residents, including care planning for daily bath preference and ensuring use of soft mitt or splint.
Failed to ensure a resident with a pressure ulcer and high risk for pressure ulcer development received care consistent with professional standards by not properly implementing an air mattress intervention.
Failed to maintain an infection prevention and control program by not ensuring staff performed appropriate infection control practices during and after incontinence care for 1 resident observed.
Report Facts
Residents reviewed: 24
Residents affected: 2
Current census: 97
Residents reviewed with pressure ulcers: 3
Residents affected by pressure ulcer deficiency: 1
Residents observed for incontinence care: 3
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1ADM | Administrator | Confirmed failure to notify Ombudsman of resident discharge |
| S15CNA | Certified Nursing Assistant | Reported Resident #26's preference for daily bath not documented |
| S14CNA | Certified Nursing Assistant | Confirmed Resident #26's daily bath preference not documented |
| S16CNA | Certified Nursing Assistant | Unaware of Resident #26's daily bath preference due to lack of documentation |
| S3ADON | Assistant Director of Nursing | Confirmed Resident #26's bath preference not documented and Resident #84 should have soft mitt or splint |
| S10MDS | MDS Coordinator | Responsible for care plans; confirmed Resident #26's preference not reflected |
| S2DON | Director of Nursing | Confirmed Resident #26's bath preference not care planned and infection control deficiencies |
| S8LPN | Licensed Practical Nurse | Observed Resident #84 without soft mitt or splint and confirmed it was required |
| S11LPN | Licensed Practical Nurse | Observed performing improper infection control during incontinence care for Resident #61 |
Inspection Report
Routine
Census: 97
Deficiencies: 9
Date: Jun 11, 2025
Visit Reason
Routine inspection of Capitol House Nursing and Rehab Center to assess compliance with regulatory requirements including resident care, infection control, hospice services, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to notify the Ombudsman of resident discharge, incomplete resident assessments, inadequate care planning, improper pressure ulcer care, unsafe IV fluid administration, unsanitary kitchen conditions, inaccurate documentation of resident care, failure to maintain hospice documentation, and lapses in infection prevention practices.
Deficiencies (9)
Failed to notify the State's Long-Term Care Ombudsman in writing of resident discharge.
Failed to complete and transmit resident discharge assessment for one resident.
Failed to develop and implement a comprehensive person-centered care plan meeting resident needs including bathing preferences and use of restraints.
Failed to ensure pressure ulcer care including proper use of air mattress for a high-risk resident.
Failed to administer IV fluids safely and appropriately including lack of daily assessment and flushing orders for midline device.
Failed to maintain sanitary conditions in kitchen including rusty ceiling vents and stained ceiling tiles.
Failed to maintain accurate documentation of resident bathing care.
Failed to maintain hospice documentation including missing hospice nurse visit notes in resident's clinical binder.
Failed to perform appropriate infection control practices during and after incontinence care including improper glove use, hand hygiene, and handling of soiled linens.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 64
Residents affected: 1
Residents affected: 1
Residents affected: 1
Current census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1ADM | Administrator | Confirmed failure to notify Ombudsman and acknowledged kitchen vent and ceiling tile issues |
| S2DON | Director of Nursing | Confirmed missing discharge assessments, care plan deficiencies, IV flushing orders missing, hospice documentation missing, and infection control lapses |
| S3ADON | Assistant Director of Nursing | Confirmed care plan and mitt/splint deficiencies |
| S4DM | Dietary Manager | Observed and confirmed unsanitary kitchen conditions |
| S5MS | Maintenance Supervisor | Responsible for kitchen vent and ceiling tile maintenance; acknowledged deficiencies |
| S6LPN | Licensed Practical Nurse | Confirmed pressure ulcer care deficiencies |
| S7LPN | Licensed Practical Nurse | Observed flushing of midline device; acknowledged lack of orders |
| S8LPN | Licensed Practical Nurse | Confirmed mitt/splint care deficiencies and hospice documentation missing |
| S10MDS | MDS Coordinator | Confirmed missing discharge assessments and care plan documentation |
| S11LPN | Licensed Practical Nurse | Observed performing improper infection control during incontinence care |
| S13CNA | Certified Nursing Assistant | Admitted to failing to document resident baths |
| S14CNA | Certified Nursing Assistant | Admitted to failing to document resident baths |
| S15CNA | Certified Nursing Assistant | Confirmed resident bathing preferences |
| S16CNA | Certified Nursing Assistant | Unaware of resident bathing preferences due to lack of documentation |
| Hospice Liaison | Confirmed missing hospice nurse visit notes | |
| Hospice Nurse | Confirmed missing hospice documentation | |
| S9CRN | Clinical Registered Nurse | Confirmed hospice documentation requirements |
Inspection Report
Routine
Deficiencies: 1
Date: Dec 26, 2024
Visit Reason
The inspection was conducted to assess the facility's maintenance services and ensure a safe, clean, comfortable, and homelike environment for residents, specifically focusing on the condition and maintenance of A/C window units in residents' rooms.
Findings
The facility failed to ensure that A/C window units in four residents' rooms were clean, free of debris, and received regular maintenance. Observations revealed buildup of black substances, mold-like spots, and gray dust on the A/C units. Facility staff confirmed that scheduled cleaning and maintenance for December had not been completed.
Deficiencies (1)
Failure to maintain A/C window units clean and free of debris, including buildup of black substances, mold-like spots, and gray dust on units in residents' rooms.
Report Facts
Residents affected: 4
Scheduled cleaning days: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2MnD | Monitored and was responsible for monthly cleaning and maintenance of A/C window units; confirmed missed maintenance in December | |
| S1ADM | Observed A/C window units and confirmed they were covered with black spots and due for cleaning and maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 13, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to treat residents with dignity, failure to timely report suspected neglect, and failure to implement care plans for pressure ulcer residents.
Complaint Details
The complaint investigation involved neglect allegations for Resident #70 related to maggots found in the resident's mouth and failure to turn the resident every 2 hours as ordered. The neglect was substantiated by observations, record reviews, and interviews confirming delays in reporting and failure to provide ordered care.
Findings
The facility failed to ensure residents were treated with respect and dignity, failed to timely report alleged neglect involving maggots found on a resident, and failed to implement care plans requiring turning and repositioning of a resident every 2 hours as ordered.
Deficiencies (3)
Failed to ensure each resident was treated with respect and dignity; staff did not communicate with the resident or explain care to be provided.
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities within 24 hours.
Failed to develop and implement a complete care plan that meets all the resident's needs; resident was not turned and repositioned every 2 hours as ordered.
Report Facts
Residents sampled for dignity: 2
Residents affected for dignity deficiency: 1
Residents sampled for pressure ulcers: 4
Residents affected for pressure ulcer deficiency: 1
Residents reviewed for neglect: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S9CNA | Observed not explaining care to Resident #82 | |
| S3ADON | Interviewed confirming expectation for staff to greet residents and explain care | |
| S2DON | Interviewed confirming expectation for staff to greet residents and explain care and confirming care plan for Resident #70 | |
| S10LPN | Signed nurse's notes regarding Resident #70 and observed exiting room before neglect incident | |
| S11CNA | Observed not entering Resident #70's room during critical time period | |
| S13LPN | Entered Resident #70's room for wound care | |
| S1ADM | Administrator interviewed confirming failure to timely report neglect and failure to provide care |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, accurate resident assessments, PASRR referrals, and food safety standards.
Findings
The facility was found deficient in ensuring residents were treated with dignity and respect, accurately reflecting resident discharge status in assessments, referring residents for required PASRR Level II evaluations, and properly storing opened food items requiring refrigeration.
Deficiencies (4)
Failed to ensure each resident was treated with respect and dignity, including staff communication and explanation of care.
Failed to ensure a resident's assessment accurately reflected discharge status.
Failed to ensure a resident with a mental health diagnosis was referred for a PASRR Level II evaluation as required.
Failed to store food in accordance with professional standards, specifically leaving opened soy sauce and lemon juice unrefrigerated.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S9CNA | Observed failing to explain care to Resident #82 | |
| S3ADON | Interviewed confirming expectation for staff to greet residents and explain care | |
| S2DON | Interviewed confirming expectation for staff to greet residents and explain care and aware of MDS discharge assessment findings | |
| S5MDS | Interviewed confirming inaccurate MDS discharge assessment for Resident #97 | |
| S8SSD | Interviewed confirming PASRR referral process and failure for Resident #4 | |
| S7DM | Interviewed confirming food storage deficiencies | |
| S1ADM | Interviewed confirming expectation for proper food storage |
Inspection Report
Census: 97
Deficiencies: 9
Date: Jul 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements based on observations, interviews, and record reviews related to resident care, medication administration, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to deliver mail on Saturdays, failure to notify physicians of changes in resident conditions, failure to administer oxygen and insulin as ordered, failure to ensure medication consumption, inadequate nail care, unsafe transfer practices, improper catheter care, uncontained outdoor trash, and incomplete vaccination documentation.
Deficiencies (9)
Failed to ensure residents received mail on Saturdays.
Failed to ensure direct care staff consulted physician and promptly notified nurse of Resident #22's skin condition change.
Failed to implement a person-centered plan of care by failing to administer oxygen as ordered for Resident #248.
Failed to ensure timely administration of insulin and observation of medication consumption for Residents #54 and #55.
Failed to provide necessary nail care for Resident #79.
Failed to ensure Resident #33's Geri chair was locked during mechanical lift transfer, causing accident hazard.
Failed to ensure urinary catheter drainage bag and tubing did not touch the floor for Resident #51.
Failed to ensure garbage and waste were properly contained in the outdoor trash compactor.
Failed to develop and implement policies and procedures ensuring resident education and documentation for flu and pneumonia vaccinations for multiple residents.
Report Facts
Residents affected: 97
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents reviewed for medication administration: 22
Residents reviewed for indwelling urinary catheters: 2
Residents reviewed for accidents: 3
Residents requiring mechanical lift transfers: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S8AD | Named in mail delivery deficiency for delivering mail Monday through Friday but not on Saturdays | |
| S10R | Named in mail delivery deficiency for receiving mail on Saturdays but not delivering it | |
| S2DON | Director of Nursing interviewed regarding mail delivery and catheter care deficiencies | |
| S18CNA | Failed to notify nurse of Resident #22's skin breakdown | |
| S15LPN | Unaware of Resident #22's skin breakdown | |
| S13WCLPN | Performed skin audit and verified nail care issues | |
| S4QARN | Confirmed pressure ulcers and oxygen order issues | |
| S14LPN | Failed to administer insulin timely and observe medication consumption | |
| S3ADON | Assistant Director of Nursing, interviewed about medication and transfer deficiencies | |
| S6NP | Nurse Practitioner, interviewed about insulin administration | |
| S17CNA | Provided care to Resident #248 and confirmed oxygen not administered | |
| S20CNA | Unaware of Resident #79's nail care needs | |
| S19CNA | Involved in unsafe transfer of Resident #33 | |
| S21CNA | Involved in unsafe transfer of Resident #33 | |
| S12LPN | Confirmed transfer requirements for Resident #33 | |
| S26MDS | Updated care plan for Resident #33 after transfer incident | |
| S22CNA | Observed catheter bag on floor for Resident #51 | |
| S14LPN | Observed catheter bag on floor for Resident #51 | |
| S5DM | Confirmed trash observations outside facility | |
| S9MS | Responsible for cleaning dumpster area during weekdays | |
| S1ADM | Administrator interviewed about dumpster area and vaccination documentation | |
| S3ADON | Unable to provide vaccination documentation |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 4, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with appropriate care standards for residents with urinary catheters, specifically to ensure proper catheter care and prevention of urinary tract infections.
Findings
The facility failed to ensure that Resident #4, who had an indwelling urinary catheter, received appropriate catheter care and monthly catheter changes as required. There were no physician orders for catheter care or changes, no documentation of catheter care or changes in the clinical record or MAR, and staff were unaware or did not implement the catheter care protocol until the issue was identified during the inspection.
Deficiencies (1)
Failure to ensure appropriate catheter care and monthly catheter changes for Resident #4 with an indwelling urinary catheter.
Report Facts
Residents reviewed with catheters: 5
Residents affected: 1
Urinary catheter insertion date: Feb 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5 CNA | Certified Nursing Assistant | Interviewed and stated Resident #4 had a urinary catheter and nurses performed daily catheter care. |
| S2 LPN | Licensed Practical Nurse | Interviewed and confirmed no catheter care or change orders for Resident #4 and was unaware of catheter presence initially. |
| S3 LPN | Licensed Practical Nurse | Interviewed and stated nurses were responsible for daily catheter care and it populated on the MAR. |
| S1 DON | Director of Nursing | Interviewed and confirmed catheter care protocol, lack of physician orders, and documentation issues for Resident #4. |
| S4 MRLPN | Licensed Practical Nurse | Interviewed and stated she was responsible for inputting residents' orders on admission and confirmed Resident #4 lacked catheter protocol orders prior to the inspection. |
| S6 NP | Nurse Practitioner | Interviewed and confirmed Resident #4 had a urinary catheter and gave orders to change the catheter on the day of inspection. |
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