Capitol House Nursing and Rehab Center
For profit - Corporation
132 Beds
Independent
Data: November 2025
Trust Grade
35/100
#188 of 264 in LA
Photo by Capitol House Nursing & Rehab Center
Photo by Capitol House Nursing & Rehab Center
Photo by Capitol House Nursing & Rehab Center
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Capitol House Nursing and Rehab Center has a Trust Grade of F, indicating significant concerns about the quality of care provided, which places it in the poor category. It ranks #188 out of 264 facilities in Louisiana, meaning it is in the bottom half of all nursing homes in the state, and #16 out of 25 in East Baton Rouge County, suggesting that there are only a few local options that are better. The facility's condition is worsening, with the number of reported issues increasing from 7 in 2024 to 9 in 2025. Staffing is a major concern here, with a low rating of 1 out of 5 stars and a troubling 62% turnover rate, which is significantly higher than the Louisiana average of 47%. While there are no fines on record, which is a positive aspect, the nursing home has less RN coverage than 91% of facilities in the state, limiting oversight for potential health issues. Specific incidents include unsanitary food storage practices, such as failing to store food properly and allowing dirty conditions in the kitchen, and neglecting to maintain clean air conditioning units in residents' rooms, which could negatively impact the living environment for residents. Overall, while there are some strengths, such as the absence of fines, the numerous concerns raise significant questions about the quality of care at this facility.
- Trust Score
- F
- In Louisiana
- #188/264
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 8 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 29%
No red flags
7 → 9 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 9 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 62%
15pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is elevated (62%)
14 points above Louisiana average of 48%
The Ugly 26 deficiencies on record
Jun 2025
9 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of discharges in writ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 1 (Resident #97) of 1 (Resident #97) sampled residents reviewed for transfer and discharge requirements.
Findings:
Review of the facility's policy titled Transfer and Discharge (including AMA) revealed in part:
Policy:
It is the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited circumstances. This policy applies to all residents regardless of their payment source.
Definitions:
Transfer and Discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not. Transfer and discharge does not refer to movement of a resident to a bed within the same facility.
5. The facility will maintain evidence that the notice was sent to the Ombudsman.
Review of Resident #97's Electronic Medical Record (EMR) revealed, in part, Resident #97 was admitted to the facility on [DATE] and was transferred from the facility to the local hospital on [DATE].
Review of the facility's Emergency Transfer Log dated 05/01/2025-05/30/2025 revealed no documentation of Resident #97's transferred to the hospital on [DATE].
Review of Resident #97's Nurse's note dated 05/07/2025 at 6:06 p.m. revealed, in part, Resident #97 was transferred on 05/07/2025 at 3:48 p.m. to a local hospital for treatment.
On 06/11/25 at 2:26 p.m., an interview was conducted with S1ADM. S1ADM confirmed the facility had not issued a written notice to the facility's assigned Ombudsman when Resident #97 transferred to a local hospital as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's discharge assessment was completed and transm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's discharge assessment was completed and transmitted for 1 (#82) of 2 (#82 and #88) residents reviewed for Resident Assessment.
Findings:
Review of the facility's policy titled, MDS (Minimum Data Set) 3.0 Completion and dated 05/2023 revealed the following, in part:
Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop and interdisciplinary care plan.
Policy Explanation and Compliance Guidelines:
2. Types of Omnibus Budget Reconciliation Act Assessments
i. Death Tracking
i. Complete when a resident expires in the facility no later than discharge (death) date plus seven calendar days.
7. Transmission Requirements:
a. All assessments shall be transmitted to the designated CMS (Centers for Medicare and Medicaid Services) system within 14 days of completion.
Review of Resident #82's Clinical Record revealed she was admitted to the facility on [DATE] and was pronounced deceased in the facility on [DATE].
Review of Resident #82's MDS assessments revealed no discharge assessment was completed.
An interview was conducted with S10MDS on [DATE] at 1:07 p.m. She confirmed Resident #82 was admitted to the facility on [DATE] and expired in the facility on [DATE]. She confirmed a discharge MDS assessment should have been completed for Resident #82's and was not.
An interview was conducted with S2DON on [DATE] at 1:29 p.m. She reviewed Resident #82's MDS assessments and confirmed a discharge assessment should have been completed and was not.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-cente...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan which met the needs of 2 (#26 and #84) of 24 residents reviewed in the final sample. The facility failed to:
1. Ensure Resident #26 was care planned for his preference of a daily bath; and
2. Ensure Resident #84's soft mitt or splint was in place on right hand at all times
This deficient practice had the potential to affect a current census of 97 residents.
Findings:
Review of the facility's policy titled Care Planning Special Needs, with a revision date of 09/2020 revealed the following:
Policy: To address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This policy pertains to the following needs: .respiratory care, prostheses .
Policy Explanation and Compliance Guidelines:
1. Comprehensive care plans will be developed based on resident assessments, goals, and preferences in accordance with assessment and care plan procedures.
6. The person-centered care plan will be developed, based on specific factors identified in assessments and physician orders, and in accordance with the resident's goals and preferences.
7. Medical conditions will be monitored and managed to prevent complications.
b. RNs and LPNs will participate in the management of medical conditions by following physician orders .
1.
Review of Resident #26's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #26's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/2025, revealed a Brief Interview of Mental Status (BIMS) of 13, which indicated he was cognitively intact. Further review revealed he was dependent on staff assistance for bathing.
Review of Resident #26's ADL (Activities of Daily Living) Flowsheet, dated June 2025, revealed Resident #26 should receive a bath on Mondays, Wednesdays, and Fridays. Further review revealed no evidence of his preference for a daily bath.
Review of the C.N.A. (Certified Nursing Assistant) Assignment Sheet, dated June 2025, revealed no documentation of Resident #26's preference for a daily bath.
Review of Resident #26's current Care Plan revealed the following:
Problem: Date initiated 05/12/2025- The resident has an ADL self-care performance deficit related to Cerebrovascular Accident with Residual Effects.
Interventions: Bathing/Showering: The resident is totally dependent on staff to provide as scheduled and as necessary. Further review revealed no documentation of the resident's preference for daily baths.
On 06/09/2025 at 10:15 a.m., an interview was conducted with Resident #26. He stated he preferred daily bed baths, and he confirmed he informed staff of him wanting daily baths.
On 06/10/2025 at 12:25 p.m., an interview was conducted with S15CNA. She stated Resident #26 preferred a daily bath. She stated his bath days on the ADL Flowsheet were scheduled for Monday, Wednesday, and Friday. She stated it was not documented anywhere Resident #26 preferred a daily bath. She stated staff who did not usually work with Resident #26, like agency staff, would not know he preferred a daily bed bath as it was not documented anywhere.
On 06/10/2025 at 1:02 p.m., an interview was conducted with S14CNA. She stated Resident #26 preferred a daily bath. She stated his bath days on the ADL Flowsheet were scheduled for Monday, Wednesday, and Friday. She stated she knew Resident #26 was a daily bed bath because the resident and the staff who trained her informed her of this. She confirmed there was no documentation of the resident's preference for daily baths.
On 06/10/2025 at 3:32 p.m., an interview was conducted with S16CNA. She stated she was assigned to Resident #26 on 06/08/2025, but was not normally assigned to him. She stated she was unaware of Resident #26's preference for a daily bath as it was not documented on the C.N.A. Assignment Sheet or the ADL Flowsheet.
On 06/11/2025 at 12:00 p.m., an interview was conducted with S3ADON. She stated Resident #26 was to receive a daily bed bath per his preference. She confirmed Resident #26's preference for a daily bath was not documented on his care plan, the C.N.A. Assignment Sheet, or ADL Flowsheet and should have been.
On 06/11/2025 at 12:22 p.m., an interview was conducted with S10MDS. She stated she was responsible for resident care plans. She stated she would care plan a resident's ADL preferences. She stated she would be notified of a resident's preferences during care plan meetings. She stated she was not aware Resident #26 preferred daily baths. She reviewed Resident #26's current care plan and confirmed Resident #26's care plan did not reflect his preference of a daily bed bath and should have.
On 06/11/2025 at 1:06 p.m., an interview was conducted with S2DON. She stated Resident #26 preferred a daily bed bath. She stated he should be care planned for his preference of a daily bath. She reviewed Resident #26's care plan, C.N.A. Assignment Sheet, and ADL Flowsheet and confirmed he was not care planned for his preference of daily baths and should have been.
2.
Review of Resident #84's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction, Gastrostomy Status, and Tracheostomy Status.
Review of Resident #84's quarterly MDS with an ARD of 05/15/2025, revealed a BIMS was not conducted due to resident being rarely or never understood, indicating severe cognitive impairment. Further review revealed the resident was totally dependent on staff for all self-care activities.
Review of Resident #84's current Physician's Orders revealed the following:
Start date: 01/09/2025 - Soft mitt to right hand with every 30 minute checks due to pulling tubing.
Review of Resident #84's current Care Plan revealed the following:
Problem: Date initiated 04/02/2025-Resident has an alteration in musculoskeletal status related to right hand contracture. Resident wears right hand splint usually during the day. Resident wears right hand soft mitt when splint not in use.
Interventions
Problem: Date initiated 01/08/2025-Resident uses physical restraints (Right hand soft mitt/guard) related to pulling of tubing.
On 06/10/2025 at 8:38 a.m., an observation was made of Resident #84 lying in bed with no soft mitt or splint noted on the resident's right hand.
On 06/10/2025 at 11:39 a.m., an observation was made of Resident #84 lying in bed with no soft mitt or splint noted on the resident's right hand.
On 06/10/2025 at 1:50 p.m., an observation was made of Resident #84 lying in bed with no soft mitt or splint noted on the resident's right hand.
On 06/10/2025 at 3:24 p.m., an interview was conducted with S8LPN. She reviewed Resident #84's current Physician's Orders, and stated Resident #84 should always have either a soft mitt or a splint on her right hand due to the possibility of the resident pulling on her tubes. S8LPN observed and confirmed Resident #84 did not have a mitt or splint in place on her right hand and should have.
On 06/10/2025 at 3:35 p.m., an interview was conducted with S3ADON. She reviewed Resident #84's Physician's Orders and confirmed Resident #84 should have a soft mitt or splint on her right hand at all times.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident with a Pressure Ulcer and at high...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident with a Pressure Ulcer and at high risk for Pressure Ulcer development received care consistent with professional standards of practice and based on the comprehensive assessment by failing to ensure an air mattress was properly implemented for 1 (#54) of 3 (#45, #54, #150) residents reviewed with Pressure Ulcers.
Findings:
Review of the facility's policy titled, Pressure Injury Prevention and Management with a revision date of 07/2024 revealed the following, in part:
Policy: This facility is committed to the prevention of avoidable pressure injuries, to provide treatment and services to heal the pressure ulcer/injury, and the development of additional pressure ulcers/injuries.
Policy Explanation and Compliance Guidelines: Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to:
Provide appropriate, pressure-distributing support surfaces.
Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Chronic Respiratory Failure, Anoxic Brain Damage, Muscle Wasting and Atrophy, and History of Pressure Ulcers.
Review of Resident #54's Quarterly MDS with an ARD of 04/15/2025 revealed a Brief Interview for Mental Status (BIMS) was unable to be conducted, which revealed she was severely cognitively impaired. Further review revealed Resident #54 was at risk for Pressure Ulcer development and was dependent on staff for turning and repositioning.
Review of Resident #54's Braden Scale for Predicting Pressure Ulcer Risk dated 04/15/2025 revealed a score of 11, which indicated she was at high risk for Pressure Ulcer development.
Review of Resident #54's current Physician Orders revealed, in part:
A Low Air Loss Mattress on her bed.
Review of Resident #54's current Care Plan revealed the following, in part:
History of Pressure Ulcers
Problem: 06/04/2025 Stage 1 Pressure Ulcer to Right Hip.
Interventions: Low Air Loss Mattress on bed.
An observation was made of Resident #54 on 06/09/2025 at 8:36 a.m. She was lying in bed. Her air mattress pump was not on.
An observation was made of Resident #54 on 06/09/2025 at 12:40 p.m. She was lying in bed. Her air mattress pump was not on.
An observation was made of Resident #54 on 06/09/2025 at 1:40 p.m. She was lying in bed. Her air mattress pump was not on.
An observation was made of Resident #54 on 06/10/2025 at 8:50 a.m. She was lying in bed. Her air mattress pump was not on.
An interview was conducted with S6LPN on 06/10/2025 at 10:16 a.m. She stated Resident #54 had a history of Pressure Ulcers and was at risk for Pressure Ulcer development. She stated Resident #54 had an air mattress in place. She stated the mattress pump should have been turned on at all times.
An observation was made of Resident #54 with S2DON on 06/10/2025 at 8:52 a.m. An interview was conducted with S2DON at that time. S2DON confirmed the air mattress pump was not on, which meant the mattress was not alternating pressure as intended. She confirmed the air mattress pump should have been on at all times. She confirmed Resident #54's air mattress was an intervention to prevent Pressure Ulcers since the resident was high risk for Pressure Ulcer development.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to administer parenteral fluids consistent with professi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1 of 1 (#300) resident reviewed for IV (Intravenous) therapy. The facility failed to monitor and flush a vascular device according to professional standards. The deficient practice had the potential to affect all residents who may require IV antibiotic or fluid therapy.
Findings:
Review of the facility's Policy dated 09/2024 titled, Intravenous Therapy-LTC revealed, in part:
Policy: The facility will adhere to accepted standards of practice regarding infusion practices.
Compliance Guidelines:
11. IV sites are checked per facility protocol .
13. IV documentation is recorded in the nurses' notes and/or Medication Administration Record (MAR).
Intermittent Medication Infusion: 1. Review and verify practitioner's order for infusion solution or medication . 13. Attach 10ml (milliliter) syringe and confirm patency of vascular access device as per protocol.
Review of Resident #300's Medical Record revealed resident was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, Acute and Chronic Respiratory Failure with Hypoxia, Pneumonia, and Tracheostomy.
Review of Resident #300's Physician Orders, dated 06/10/2025, revealed an order on 06/09/2025 for Midline placement today, and Meropenem Solution Reconstituted 1 GM (gram), use 1 gram intravenously every twelve hours for Klebsiella Pneumoniae for 14 days. Further review revealed no physician orders for an assessment daily, dressing changes, or flushing schedule for Resident #300's maintenance of the Midline venous access device.
Review of Resident #300's Medication Administration Record (MAR), dated 06/10/2025, revealed no documented evidence of an assessment daily or flushing schedule for Resident #300's Midline device.
On 06/10/2025 at 9:00 a.m., an observation was made of Resident #300's Midline vascular access site in the left, upper arm, during medication administration. S7LPN scrubbed the hub with alcohol for 20 seconds, connected a NS (normal saline) syringe and flushed the Midline device.
On 06/10/2025 an interview was conducted with S7LPN, after medication infusion was started. SLPN stated that she knew the device was patent because she observed it being inserted into Resident's left arm yesterday.
On 06/10/2025 at 4:25 p.m., an interview was conducted with S2DON. S2DON stated all nurses were responsible for ensuring appropriate orders for each resident are documented. S2DON stated she expected nurses to flush a Midline access device in between medication administration with saline and heparin to maintain patency. She reviewed Resident #300's current physician orders and confirmed there was not an order for daily assessment of or flushing her Midline IV device and should have been. She confirmed the nurse should have notified the Practitioner for missing flush orders and documented on MAR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#26) of 3 (#10, #19, and #26) residents reviewed for Activities of Daily Living (ADL). The facility failed to ensure nursing staff accurately documented Resident #26's baths.
Findings:
Review of Resident #26's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #26's Quarterly MDS with an ARD of 04/28/2025 revealed he was dependent on staff assistance for bathing.
Review of the C.N.A. (Certified Nursing Assistant) Assignment Sheet dated June 2025 revealed Resident #26 should receive a bath Monday through Saturday.
Review of Resident #26's ADL (Activities of Daily Living) Flowsheet dated 06/01/2025 to 06/11/2025 revealed no documentation a bath was given on 06/03/2025, 06/05/2025 or 06/07/2025.
Review of Resident #26's Nurses' Notes dated June 2025 revealed no documented evidence of refusals of baths.
On 06/10/2025 at 3:22 p.m., a telephone interview was conducted with S13CNA. She verified she was assigned to Resident #26 on 06/07/2025 and gave him a bed bath. She confirmed she did not document his bed bath on 06/07/2025, and should have.
On 06/11/2025 at 11:52 a.m., an interview was conducted with S14CNA. She verified she was assigned to Resident #26 on 06/03/2025 and 06/05/2025 and gave Resident #26 a bed bath. She reviewed Resident #26's ADL Flowsheet dated June 2025 and confirmed she did not document the baths were given. She confirmed Resident #26's baths were not accurately documented and should have been.
On 06/11/2025 at 12:00 p.m., an interview was conducted with S3ADON. She stated Resident #26 was to receive a daily bed bath. She reviewed Resident #26's ADL Flowsheet dated June 2025 and confirmed the CNAs were not documenting the daily baths. She confirmed the documentation did not show a bath was performed on the above mentioned dates and should have.
On 06/11/2025 at 1:06 p.m., an interview was conducted with S2DON. She stated Resident #26 preferred a daily bed bath. She reviewed Resident #26's ADL Flowsheet dated June 2025 and confirmed there was no documentation Resident #26 received a bath on the above mentioned dates. She confirmed Resident #26's baths were not accurately documented and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to meet Hospice requirements by failing to maintain a system to ensu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to meet Hospice requirements by failing to maintain a system to ensure a hospice resident's Clinical Binder contained documentation of Hospice Nurse Visit notes for 1 (#81) of 1 resident reviewed for hospice care.
This deficient practice had the potential to affect any of the residents receiving hospice services in the facility.
Findings:
Review of the facility's policy titled Hospice Services Facility Agreement, with a revision date of 10/2020 revealed the following:
Policy: It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility.
A review of Resident #81's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #81 was a patient of a local hospice agency with a Certification Period of 04/03/2025 through 07/01/2025.
A review of Resident #81's hospice binder revealed resident was admitted to the hospice agency on 04/03/2025. Further review revealed no Hospice Nurse Visit notes were contained in the binder.
On 06/10/25 at 3:52 p.m. an interview was conducted with the Hospice Liaison. She reviewed Resident #81's hospice binder and confirmed there were no hospice progress notes in the binder.
On 06/10/25 at 4:37 p.m. an interview was conducted with S8LPN. She reviewed Resident #81's hospice binder and confirmed there were no hospice progress notes in the binder.
On 06/11/25 at 11:42 a.m. an interview was conducted with hospice nurse. She confirmed she had not placed documentation with resident #81's weekly assessments in the facility's hospice binder.
On 06/11/25 at 2:10 p.m. an interview was conducted with S9CRN. She confirmed hospice progress notes should be updated and kept in the resident's hospice binder.
On 6/11/25 at 2:10 p.m. an interview was conducted with S2DON. She confirmed hospice progress notes should be updated and kept in the resident's hospice binder.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the...
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Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable infection by failing to ensure staff performed appropriate infection control practices during and after incontinence care for 1 (#61) of 3 (#19, #37, and #61) residents observed for incontinence care.
Findings:
Review of the facility's policy titled, Catheter Care revealed the following, in part:
Policy: It is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter care.
Compliance Guidelines: Female
Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap).
Review of the facility's policy titled, Hand Hygiene revealed the following, in part:
Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, patients, residents, and visitors.
Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene may be performed by using both soap and water or alcohol based hand rub. Hand hygiene should be performed during resident care when moving from a contaminated body site to a clean site.
Review of Resident #61's current Physician Orders revealed, in part, to cleanse her catheter daily and as needed with soap and water.
On 06/11/2025 at 9:00 a.m., an observation was made of S11LPN performing catheter and incontinence care on Resident #61. S11LPN donned clean gloves and used clean perineal wipes to remove bowel movement off of Resident #61's buttocks. S11LPN then, without changing gloves or performing hand hygiene, placed a clean sheet over Resident #61's torso with her soiled gloves. S11LPN removed her soiled gloves and applied clean gloves without performing hand hygiene. S11LPN obtained a clean wash cloth with soap and water, removed bowel movement off of Resident #61's catheter tubing and then used a perineal wipe to clean bowel movement off of Resident #61's catheter tubing. S11LPN removed her soiled gloves and applied clean gloves without performing hand hygiene. S11LPN then used five wash cloths to clean Resident #61's perineum and each time, placed the soiled wash cloths on the floor. S11LPN obtained a perineal wipe and cleaned bowel movement off of Resident # 61's buttocks, wiping toward the catheter tubing and vaginal area. Then without changing her gloves or performing hand hygiene, S11LPN opened a clean incontinence pad and placed it under Resident #61 with her soiled gloves. S11LPN, without changing gloves or performing hand hygiene, touched Resident #61's right arm and torso to turn Resident #61 toward S11LPN, touched the inside of Resident #61's clean brief, fastened Resident #61's brief, pulled Resident #61's gown down, and placed the sheets and blankets on Resident #61 with soiled gloves. S11LPN opened Resident #61's room door, removed her gown and gloves and exited Resident #61's room without performing hand hygiene. S11LPN went to another hall in the facility, retrieved a linen cart, placed a clean trash bag in the linen cart and put the lid down. Then without performing hand hygiene and using her soiled hands, S11LPN opened the Personal Protective Equipment cart drawer and put on a gown. S11LPN used her soiled hands to tie the gown around her waist and behind her neck.
On 06/11/2025 at 9:40 a.m., an interview was conducted with S11LPN. S11LPN confirmed she should have removed her soiled gloves and applied clean gloves after removing bowel movement form Resident #61 and prior to moving to a clean area. S11LPN confirmed she did not perform hand hygiene between glove changes and after removing soiled gloves, and should have. S11LPN confirmed she placed soiled linen on the floor, and should not have. S11LPN confirmed she exited Resident #61's room and retrieved a soiled linen cart from another hallway without sanitizing her hands. S11LPN confirmed she should have wiped away from Resident #61's catheter tubing and vaginal area when removing bowel movement.
On 06/11/2025 at 10:57 a.m., an interview was conducted with S2DON. S2DON confirmed staff should change their gloves when soiled and when moving from a contaminated to a clean area during resident care. S2DON confirmed staff should sanitize their hands between glove changes. S2DON confirmed staff should wipe from front to back in a female and should wipe away from catheter tubing while performing incontinence care. S2DON confirmed staff should place dirty linens into the dirty linen basin. S2DON confirmed soiled linen should not have been placed onto the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to store and prepare food under sanitary conditions by failing to ensure:
1. Ceiling vents in the kitchen were clean, free of rust and debris;...
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Based on observations and interviews, the facility failed to store and prepare food under sanitary conditions by failing to ensure:
1. Ceiling vents in the kitchen were clean, free of rust and debris;
2. Ceiling tiles (6) in the kitchen and (2) in the adjacent Dining areas were free from water stains.
The deficiency had the potential to affect 64 residents who were served meals from the kitchen.
Findings:
On 06/09/2025 at 8:13 a.m., the initial tour of the facility's kitchen was conducted with S4DM. The following observations were made in the presence of S4DM during the initial tour:
Main Kitchen/cooking Area:
Rusty orange and dirty brown large ceiling vent coverings above serving steam table;
Rust stains and flakey black debris noted on large ceiling vent covering in dishwashing room;
Ceiling tiles (6), ranging from baseball to softball size, contained stains in main kitchen.
On 06/09/2025 at 8:40 a.m., an interview was conducted with S4DM. She verified the ceiling vent coverings were dirty, rusty, and needed cleaning in the main kitchen, dining, and dishwasher room areas. She stated she did not know date of last cleanings performed. She stated S5MS was responsible for cleaning and replacements of all kitchen ceiling vent covers and ceiling tiles.
On 06/11/2025 at 8:05 a.m., an observation was made of ceiling tiles in kitchen and above steam serving table with baseball size stain and 2 appromimate16X20 vents with large amount of rust covering entire surface; ceiling tiles (6) in main cooking area of kitchen observed with water stains in size ranging from baseball to softball size. S4DM confirmed aforementioned findings. S4DM stated she did not think areas could be cleaned at this point in time. She stated S5MS was aware of current condition of vents and ceiling tiles.
On 06/11/2025 an interview with S5MS was conducted at 8:45 a.m. He stated he was aware of the water stained ceiling tiles (6) and ventilation coverings in the kitchen locations. He further stated the issues were caused by the air condition system, which was located right above the main kitchen area. S5MS confirmed he was responsible for monitoring and cleaning all ventilation coverings and ceiling tiles. He stated he had painted over ceiling vent covering in dishwashing room and had not replaced with a new covering. He confirmed the tiles and covering should have been maintained under sanitary conditions.
On 06/11/2025 an interview with S1ADM was conducted at 8:45 a.m. S1ADM confirmed there was rust on the ventilation coverings in the kitchen areas and six ceiling tiles contained water stains. S1ADM confirmed the ceiling tiles and vent coverings should have been replaced to maintain sanitary conditions in the kitchen and dining room areas, and were not.
Dec 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure maintenance services were provided to maintain a safe, clean...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure maintenance services were provided to maintain a safe, clean, comfortable, and homelike environment for 4 of 4 (#R1, #R2, #R3 and #R4) residents' rooms observed for environmental concerns. The facility failed to ensure A/C (air conditioning) window units were clean, free of debris, and received regular maintenance
Findings:
Resident #R1
Review of Resident #R1's Clinical Record revealed she was admitted to the facility on [DATE] with a BIMs of 15, which indicated cognitively intact.
An observation was made on 12/23/2024 at 10:30 a.m. of Resident #R1's room A/C window unit. The right and left adjustable louvers of the A/C window unit were covered throughout with a buildup of black substances, spotted flat black stains and a blue glove stuffed into a crevice of one of the louvers. Further observation of the A/C window unit revealed the front panel grill had a buildup of gray dust.
An interview was conducted on 12/23/2024 at 10:30 a.m. with Resident #R1. Resident #R1 stated she had her A/C window unit running all the time. Resident #R1 observed the A/C window unit, and she confirmed there were multiple black spots that looked like mold on the adjustable louvers and gray dust buildup on the front panel grill of the A/C window unit. She stated the A/C window unit needed to be cleaned. She stated she had trouble with allergies and was worried the state of the A/C window unit could have caused an increase in her allergy symptoms.
Resident #R2's
An observation was made of on 12/23/2024 at 10:38 a.m. of Resident #R3's A/C window unit in her room. Observed the right and left adjustable louvers of the A/C window unit were spotted with a buildup of black substances and spotted, flat, black stains. Further observation of the A/C window unit revealed the front panel grill had a buildup of gray dust.
Resident #R3 and Resident #R4
An observation was made on 12/23/2024 at 10:40 a.m. of Room c's A/C window unit. Observed the right and left adjustable louvers of the A/C window unit were spotted with a buildup of black substances and spotted, flat, black stains. Further observation of the A/C window unit revealed the front panel grill had a buildup of gray dust.
Review of facility's documentation of Central A/C Filter Monthly Log revealed the following:
November:
Inspected- maintenance
Replaced- cleaned/replaced
December:
Inspected-blank
Replaced-blank
A facility tour and interview was conducted on 12/23/2024 at 2:00 p.m. with S2MnD. S2MnD stated he monitored and was responsible for the monthly cleaning and maintenance of the A/C window units in the facility. During the tour, S2MnD observed the aforementioned Resident #R1, Resident #R2, Resident #R3 and Resident #R4's A/C window units, and he confirmed they were covered with black spots which looked like mildew. S2MnD confirmed the A/C window units were usually cleaned and maintenance completed once a month on the 15th and 16th day. He stated the A/C window units were due to be cleaned and filter replaced on 12/15/2024 and 12/16/2024, but had not completed the services.
A facility tour and interview was conducted on 12/23/2024 at 2:45 p.m. with S1ADM. S1ADM observed the aforementioned A/C window units, and she confirmed they were covered with black spots and were due to be cleaned and maintenance.
Jun 2024
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure each resident was treated with respect and di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#82) of 2 (#59 and #82) sampled residents reviewed for dignity. The facility failed to ensure staff communicated with the resident, and explained the care to be provided.
Findings:
Review of Resident #82's Clinical Record revealed he was admitted on [DATE] with diagnoses, which included Cerebral Infarction, Tracheostomy, and Need for Assistance with Personal Care.
Review of Resident #82's admission assessment MDS with an ARD of 05/21/2024 revealed the provider assessed the resident as having a BIMS of 0, indicating the resident was severely cognitively impaired. Further review revealed he was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene.
On 06/10/2024 at 10:20 a.m., an observation was conducted of Resident #82. S9CNA walked into Resident #82's room, pulled the curtain, and pulled the sheet to turn Resident #82 without explaining the care to be provided.
On 06/12/2024 at 3:09 p.m., an interview was conducted with S3ADON. She confirmed she would expect all staff to greet residents when entering the room and explain the care to be provided.
On 06/12/2024 at 3:30 p.m., an interview was conducted with S2DON. She confirmed she would expect all staff to greet residents when entering the room and explain care to be provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure alleged violations involving neglect were reported immediat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure alleged violations involving neglect were reported immediately to the Administrator and within 24(twenty four) hours after the allegations were made to the state agency for 1of 1 (#70) residents reviewed for neglect.
Findings:
A review of the facility's policy titled, Reporting Alleged Violations revealed, in part, the following:
Policy:
The purpose of this policy is to assure that all alleged violations are reported immediately to the facility administrator and other officials.
Compliance Guidelines:
2. If the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately but no later than 2 hours after the allegation is made.
4. The alleged violations must be reported to the administrator of the facility and to other officials (including to the State Agency and Adult Protective Services where state law provides jurisdiction in long term care facilities) in accordance with state law through established procedures.
A review of the clinical record revealed Resident #70 was admitted to the facility on [DATE]. Resident #70's diagnosis included Encounter for Attention to Tracheostomy.
A review of Resident #70's Nurse's Notes from 05/17/2024 revealed:
05/17/2024 at 4:00a.m.- Signed by S10LPN- Summoned to room by charge nurse while assisting with care of resident. Upon entering resident room, resident lying with head turned to right side. Condition stable. Resident noted to have large amount of larvae exiting from mouth area. Ambulance called to transport resident out of facility.
A review of the facility's Investigative Report turned in to state agency revealed the incident with Resident #70 having maggots coming from his mouth was discovered on 05/17/2024 at 5:00 a.m. Further review revealed an investigative report was not entered into the system until 05/20/2024 at 12:18 p.m.
On 06/12/2024 at 3:05 p.m., an interview was conducted with S1ADM. She confirmed she did not report the incident within 24 hours to the state agency. She confirmed she reported the incident on 05/20/2024 and it should have been reported within 24 hours of the incident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's assessment accurately reflected the discharge...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's assessment accurately reflected the discharge status for 1(#97) of 5 (#52, #64, #82, #97 and #450) residents reviewed for hospitalizations.
Findings:
Review of Resident #97's MDS Discharge assessment dated [DATE] revealed the resident was discharged to a general hospital.
Review of Nursing Notes for Resident #97 revealed the following, in part:
05/09/2024 at 4:58 p.m., Resident #97's son in facility loading up all resident belongings. Resident #97 was given her signed copy of medication with all narcotics. Resident #97 was also given paperwork from the social worker. Resident #97 was rolled to private transportation and assisted by son into car.
On 06/12/2024 at 2:38 p.m., an interview was conducted with S5MDS. She reviewed Resident #97's MDS Discharge Assessment and confirmed it indicated Resident #97 was discharged to a general hospital. She reviewed Resident #97's medical record and confirmed the resident was discharged home. She confirmed the resident's MDS Discharge Assessment was not coded correctly and should have been coded discharged home.
On 06/12/2024 at 2:46 p.m., an interview was conducted with S2DON. She was made aware of the findings and confirmed the MDS Discharge Assessment should be accurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, 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 for 1(#4) of 3(#4, #77, and #90) sampled residents records reviewed for PASRR.
Findings:
Review of the Clinical Record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia. Further review revealed additional medical diagnoses of Anxiety disorder (11/12/2019), Schizoaffective Disorder (10/11/2017), and Unspecified Psychosis (06/06/2014). Further review of the clinical record revealed no documentation of a Level II PASRR evaluation.
On 06/12/2024 at 1:30 p.m., an interview was conducted with S8SSD. She stated when a resident acquired a new mental health diagnosis she submitted a request to the state agency for a PASRR Level II referral. She reviewed the PASRR Level I on file for Resident #4 dated 01/15/2013. She confirmed Resident #4 had acquired the above listed diagnosis since the last Resident Review submission. She confirmed a Resident Review form should have been submitted for evaluation and determination for Level II services and was not.
On 06/12/2024 at 1:45 p.m., an interview was conducted with S2DON. She reviewed the PASRR Level I on file for Resident #4 dated 01/15/2013. She confirmed Resident #4 had acquired the above listed diagnosis since the last Resident Review submission. She confirmed a Resident Review form should have been submitted for evaluation and determination for Level II services and was not.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the provider failed to ensure the care plan was implemented for 1 ( #70) of 4 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the provider failed to ensure the care plan was implemented for 1 ( #70) of 4 (#67, #70, #77, and #299) residents sampled for Pressure Ulcers were turned and repositioned every 2 hours per Physician Orders.
Findings:
Review of Resident #70's face sheet/clinical record revealed the resident was admitted to the facility on [DATE]. Resident #70's diagnosis included, in part: Unspecified Open Wound of Lower Back and Pelvis.
Review of Resident #70's Physician Orders from April 2024 to current revealed the following, in part,
04/23/2024 Every 2 hour turns.
Review of Resident #70's current Care Plan revealed;
Problem Onset: 12/04/2023- I have a stage 4 to my Right Shoulder. I receive wound care as ordered by my Physician.
Intervention: Every 2 hours turn and reposition as needed.
On 06/13/2024 at 8:30 a.m., an observation was made with S1ADM of the facility's video surveillance of Resident #70's room on 05/16/2024 from 7:30 p.m. until 05/17/2024 at 4:00 a.m. S10LPN exited Resident #70's room on 05/16/2024 at 9:19 p.m. S11CNA's shift started on 05/16/2024 at 10 p.m. S11CNA never entered Resident #70's room until 05/17/2024 at 3:48 a.m. No nursing or CNA staff entered the room until 05/17/2024 at 3:40 a.m., when S13LPN entered room for wound care.
On 06/13/2024 at 10:00 a.m., an interview was conducted with S1ADM. S1ADM verified a nurse did not enter Resident #70's room on 05/16/2024 from 9:19 p.m. until 05/17/2024 at 3:40 a.m. She also verified a CNA did not enter Resident #70's room on 05/16/2024 from 9:48 p.m. until 05/17/2024 at 3:48 a.m. She stated that nurses and CNAs should be making rounds every 2 hours and she confirmed they did not.
On 06/13/2024 at 1:10 p.m., an interview was conducted with S2DON. She reviewed Resident #70's care plan. She confirmed Resident #70's care plan had an intervention for him to be turned every 2 hours. She further confirmed the CNA or nurse did not enter Resident # 70's room from 5/16/2024 at 9:48 p.m. until 05/17/2024 at 3:40 a.m. She stated Resident #70 should have been turned and repositioned every 2 hours and he was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 78 residents ...
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Based on observation, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 78 residents who were served meals from the kitchen.
Findings:
Review of the facility's policy titled, Food Safety Requirements, dated 08/2022, revealed in part:
Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety.
3. Facility staff shall inspect all food, food products, and beverages upon receipt and ensure proper storage
a. Refrigerated storage-foods that require refrigeration shall be refrigerated immediately upon receipt.
On 06/10/2024 at 9:00 a.m., an initial tour of the kitchen was conducted with S7DM. The following items were found opened on a shelf instead of in the refrigerator:
1. Soy Sauce, 1 gallon bottle, half empty. Manufacture's label read Refrigerate After Opening.
2. Lemon Juice, 1 quart bottle, half empty. Manufacture's label read Refrigerate After Opening.
On 06/10/2024 at 9:02 a.m., an interview was conducted with S7DM. She confirmed the soy sauce and lemon juice were open. She confirmed both the soy sauce and lemon juice should have been refrigerated upon opening and was not.
On 06/11/2024 at 10:00 a.m., an interview was conducted with S1ADM. She stated she expected all opened food items which require refrigeration would be stored in the refrigerator.
Jul 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure direct care staff consulted with the physician...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure direct care staff consulted with the physician when there was a need to alter treatment for 1 (#22) of 4 (#22, #54. #55 and #148) sampled residents reviewed. The facility failed to ensure CNA staff promptly notified the nurse when she identified Resident #22 had a change in her skin condition.
Findings:
Review of the policy titled Notification of Changes revealed the following, in part:
Policy
The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's Physician, and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.
Definitions:
Need to alter treatments significantly- commence a new form of treatment to deal with the problem.
Compliance Guidelines:
The facility must inform the resident, consult with the resident's physician when there is a change requiring such notification.
Circumstances requiring notification include:
3. Circumstances that require a need to alter treatment may include:
a. New treatment
Review of Resident #22's Clinical Record revealed she was admitted to the facility on [DATE]. Resident #22 had diagnoses which included Muscle Wasting and Atrophy, Cellulitis of Left Lower Limb, Peripheral Vascular Disease, and Type II Diabetes Mellitus.
Review of Resident #22's Annual MDS with an ARD of 06/24/2023 revealed she had a BIMS of 13, which indicated she was cognitively intact. Resident #22 was assessed by the facility as being always incontinent of urine, always incontinent of bowel, and extensive assistance on staff for toileting and transfers. Further review revealed the facility assessed Resident #22 as being at risk for developing pressure ulcers/injuries.
An interview was conducted on 07/24/2023 at 11:30 a.m. with Resident #22. Resident #22 said she had pain to her right buttock area. She said she told S18CNA this morning while she was providing ADL care that she had pain. She said she was unsure if she had a pressure ulcer to her buttock area.
An interview was conducted on 07/24/2023 at 11:35 a.m. with S18CNA. She said while providing Resident #22's bath this morning, she noticed small areas under her right buttock which appeared to be open wounds. She said the skin was rubbed off under Resident #22's right buttock. She said she did not notify Resident #22's nurse.
An interview was conducted on 07/24/2023 at 11:45 a.m. with S15LPN. She said she was unaware of skin breakdown to Resident #22's right buttock area. She said S18CNA had not informed her she had identified skin breakdown to Resident #22's right buttock area.
An interview was conducted on 07/24/2023 at 11:55 a.m. with S13WCLPN. She said she was unaware if Resident #22 had skin breakdown to her buttock area.
An observation was made on 07/24/2023 at 12:46 p.m. of S13WCLPN performing a body audit of Resident #22. During the skin audit, 6 round areas of open skin were noted to Resident #22's right buttock/upper thigh area. S13WCLPN said S18CNA should have reported the open areas of skin to Resident #22's nurse when she first identified them while providing a bath to Resident #22 this morning. She confirmed she was unaware until now that Resident #22 had areas of open skin to her buttock/upper thigh area.
An interview was conducted on 07/25/2023 at 10:00 a.m. with S4QARN. She confirmed Resident #22 had six Stage II Pressure Ulcers to her right buttock/thigh area. She said S18CNA should have immediately notified Resident #22's nurse upon discovery of the skin breakdown to her right buttock area.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards for 2 (#54 and #55) of 22 residents reviewed in the final sample for medication administration. The facility failed to ensure:
1. Resident #54 received his sliding scale insulin 30 minutes prior to lunch and
2. Staff observed Resident #55 consume his medications prior to exiting his room.
Findings:
Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part:
3. Development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with compassion, including increased and ongoing development of self-awareness, sound judgement, [NAME], ethical thing and behaviors, problem solving and critical thinking abilities.
7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team.
Review of the facility's policy titled Medication Administration revealed the following, in part:
Policy Explanation and Compliance Guidelines:
15. Observe resident consumption of medication.
Review of the facility's policy titled Timely Administration of Insulin revealed the following, in part:
Policy: It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition.
Policy Explanation and Compliance Guidelines:
4. Insulin administration will be coordinated with meal times and bedtime snacks unless otherwise specified in the physician order.
5. e. Administer at appropriate times.
Review of the Manufacturer Packaging Insert titled Humulin R Insulin -Human Injection Patient Information revealed the following, in part:
Use Humulin R 30 minutes before eating a meal.
Resident #54
Review of Resident #54's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus.
Review of Resident #54's MDS with an ARD of 06/07/2023 revealed he had a BIMS of 15, which indicated he was cognitively intact.
Review of Resident #54's current Physician Orders revealed the following, in part:
03/30/2023 Humulin Regular Insulin Sliding Scale if:
Blood Glucose <60 give juice/carb and call NP, repeat blood glucose in 30 minutes, 0-199- 0 units, 200 -250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10 units, 401-450 12 units, Greater 450 14 units and notify provider.
An interview was conducted on 07/24/2023 at 1:10 p.m. with Resident #54. He said he often did not receive his sliding scale insulin dose after the nurse obtained an accucheck prior to his lunch meal. He said the nurse would tell him she would be back to give him his insulin before he ate his lunch and would not return to administer his insulin. He said the nurse obtained his accucheck today at 10:45 a.m. and had not come back to give his insulin. He said he ate his lunch meal at 11:30 a.m. today.
An interview was conducted on 07/24/2023 at 1:30 p.m. with S14LPN. She verified she obtained Resident #54's accucheck at 10:45 a.m. today and his blood glucose was 279. She confirmed he ate his lunch at 11:30 a.m. today. She said she should have administered Humulin R 6 units SQ 30 minutes prior to Resident #54's lunch meal and had not.
An observation was made on 07/24/2023 at 1:40 p.m. of S14LPN administering 6 units of Humulin R SQ to Resident #54's left upper arm. S14LPN did not recheck Resident #54's accucheck prior to administering 6 units of Humulin R SQ.
An interview was conducted on 07/24/2023 at 3:00 p.m. with S3ADON. She said Resident #54 should have received his sliding scale insulin dose 30 minutes prior to his lunch meal.
An interview was conducted on 07/25/2023 at 9:00 a.m. with S6NP. He said he expected the nurses to administer all resident's sliding scale insulin 30 minutes prior to each meal. He said S14LPN should have rechecked Resident #54's accucheck prior to administering Humulin R 6 units SQ.
Resident #55
Review of Resident #55's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease without Heart Failure.
Review of Resident #55's MDS with an ARD of 06/19/2023 revealed he had a BIMS of 15, which indicated he was cognitively intact.
Review of Resident #55's current Physician Orders revealed the following, in part:
06/12/2023 Hydralazine 50 mg tablet give one tablet by mouth three times daily.
An observation was made on 07/24/2023 at 9:00 a.m. of Resident #55. Resident #55 was sitting in his bed with two orange tablets noted on his white T-shirt. He said he often took his medication too quickly and the pills would accidentally spill in his bed or onto the floor. He said S14LPN administered his medications this morning.
An interview was conducted on 07/24/2023 at 9:05 a.m. with S14LPN. She said the two orange tablets on Resident #55's white T-shirt were Hydralazine. She said she administered one of the Hydralazine tablets this morning at 8:00 a.m. She said she was unsure if one of the orange tablets was from this morning's medication administration. She confirmed Resident #55 received Hydralazine 50 mg by mouth three times a day.
An interview was conducted on 07/24/2023 at 9:10 a.m. with S3ADON. She confirmed there were two orange tablets on Resident #55's white T-shirt. She said the nursing staff should always ensure the residents swallow their medication prior to exiting the room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure 1 (#79) of 1 (#79) residents reviewed for act...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure 1 (#79) of 1 (#79) residents reviewed for activities of daily living, received the necessary services to maintain personal hygiene for nail care.
Findings:
Review of the facility's policy titled Activities of Daily Living revealed, in part:
Care and services will be provided for the following activities of daily living:
1. Bathing, dressing, grooming and oral care.
Policy explanation and compliance guidelines:
3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene.
Review of the facility's policy titled Providing Nail Care revealed, in part:
Policy explanation and compliance guidelines:
1. Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible.
3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis.
4. Principles of nail care:
a. Nails should be kept smooth to avoid skin injury.
Resident #79
Review of Resident #79's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side; Mixed Receptive-Expressive Language Disorder, Depression, Unspecified Lack of Coordination; Other Symptoms and Signs involving Cognitive Functions Following Other Cerebrovascular Disease, and Idiopathic Gout, Unspecified Site.
Review of Resident #79's quarterly MDS with an ARD of 05/31/2023 revealed BIMS of 10, with moderate cognitive impairment. Further MDS review revealed Resident #79 required extensive one-person assistance for personal hygiene, and bathing.
Review of Resident #79's Care Plan dated 09/09/2022 revealed the resident was care planned for needing assistance with all ADLs due to diagnosis of Hemiplegia.
An observation of Resident #79 was made on 07/25/2023 at 11:00 a.m. He was observed to have long, thick, and untrimmed fingernails on both hands.
An interview with Resident #79 was conducted on 07/25/2023 at 11:05 a.m. He stated he would like his fingernails cut and no one has cut them recently.
An interview with S20CNA was conducted on 07/25/2023 at 11:10 a.m. She stated Resident #79 had not requested his nails to be cut, and she was unaware they needed it.
An observation of Resident #79 was made on 07/26/2023 at 9:00 a.m. Resident #79's fingernails on both hands remained long, thick, and untrimmed.
An interview with S14LPN was conducted on 07/25/2023 at 11:10 a.m. She verified she was assigned to Resident #79's care. She stated the nurses or CNAs could trim fingernails. She stated the podiatrist cut all toenails. She stated no clients should have long, untrimmed fingernails. She confirmed Resident #79's fingernails were long, thick, and untrimmed.
An interview with S2DON was conducted on 07/26/2023 at 1:35 p.m. She confirmed Resident #79 had long, thick, and untrimmed fingernails. She stated staff were aware that he needed his nails trimmed. She stated any nurse or CNA could trim fingernails. She stated S13WCLPN usually trimmed Resident #79's fingernails because he required special clippers to cut his thick nails. She was unable to provide documentation that nail care had been done for Resident #79.
An interview with S13WCLPN was conducted on 07/26/2023 at 1:40 p.m. She verified Resident #79's fingernails were long, thick, and untrimmed. She also verified she has never trimmed his nails, and stated the resident needed a physician's appointment to get them trimmed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's environment remained free of accident hazards ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's environment remained free of accident hazards for 1 (#33) of 3 (#23, #33, and #67) residents reviewed for Accidents. The facility failed to ensure the Geri chair was locked when Resident (#33) was transferred with a mechanical lift as identified in the plan of care. There were 43 total residents identified on the facility's census that required mechanical lift transfers.
Findings:
Review of the facility's Policy titled Safe Patient Handling and Transfers revealed, in part:
Policy: it is the policy of this facility to ensure that patients/residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the patient/resident while keeping the employees safe in accordance with current standards and guidelines.
Procedure: Educate direct care personnel on all transfer equipment, safe body mechanics for lift/transfer techniques.
A. Education shall be completed at initial orientation and at annual skills fair.
Review of the facility's Policy titled Hoyer Lift revealed, in part:
Policy:
A Hoyer Lift should be utilized on any Patient where there is question of maintaining Patient or Staff Safety during the transfer of the Patient.
Review of facility's Incident Reports revealed, in part:
03/15/2023: Incident Type: Head Injury;
Time: 1:50 p.m.- Reported to Supervisor by S23LPN. Incident reported by S24CNA;
Description of Incident:
Reported by CNA resident was hit in the head by Hoyer lift during transfer. Resident complained of headache and swelling noted to top of resident head. Ice Pack applied to head for swelling and 2 Tylenol 325mg each administered. RP notified at 2:00 p.m.; S6NP notified at 1:57p.m.
Facility investigation: In-services provided to CNA/LPN staff on Hoyer lift on 03/15/2023, and on dates from 3/16/2023-3/18/2023- signed S25PQARN.
07/24/2023 Incident type: Fall/ No Head injury;
Time: 11:20 a.m. reported to Supervisor by S11LPN. Incident reported by S21CNA.
Description of Incident:
Resident being transferred from bed to Geri chair with Hoyer lift x 2 persons; she stated while transfer, the resident chair tilted and I remained holding the resident with another CNA help ease her to the floor; resident c/o bilateral ankle pain after placed into bed.
Pain level:3; RP/NP notified;
Facility investigation: Resident assessed for injury, none observed or noted; denied need for pain med; did c/o initial tenderness to left knee and bilateral ankles; Refuse any pain meds. New order per S6NP for x-ray of left knee and bilateral ankles; resident a 3 person transfer to and from bed to Geri chair; staff educated on Geri chair to be locked and secured for safe transfer. Staff to make sure 2 staff members are to side of Hoyer and 1 to rear for safe transfers; therapy to assess for safe transfer and educate; New chair to be ordered for proper fit and safety with transfers; Signed S4QARN.
Review of Nurses notes revealed, in part:
03/15/2023 2:07 p.m.- Reported by CNA resident hit in head by Hoyer lift during transfer. C/o Headache and swelling to top of head. Ice pack applied to head for swelling, and 2 Tylenol 325mg tablets administered; Notified S6NP- Verbal order to monitor and call PRN if changes; Attempted 2 times to notify son. No answer. Signed S23LPN.
07/24/2023 12:54 p.m.- nurse called to room per S19CNA that she needed nurse immediately at 11:15 a.m. upon enter room nurse noted resident on floor, awake, alert with eyes open. Resident removed from the floor, nurse asked her was she hurting, she stated no. Removed off floor x 4 person with Hoyer lift without problems, place back to bed. Head to toe assessment done. Resident stated her ankles were hurting. Acetaminophen 325mg x 2 po given. S6NP notified; RP called; Left message to call nursing home. Resident didn't hit her head when eased to floor per S19CNA and S21CNA. Signed S11LPN.
Review of the clinical record for Resident #33 revealed she was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic Congestive Heart Failure, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites- Right Shoulder, Left Shoulder; Hemiplegia and Hemiparesis following Cerebral Infarction Affective Left Non-Dominant Side; Other Specified Arthritis, Right Knee, Cognitive Social or Emotional Deficit Following Other Cerebrovascular Disease, and Morbid Obesity.
Review of the Quarterly MDS with ARD of 04/19/2023 for Resident #33 revealed a BIMS of 15, which indicated resident was cognitively intact with appropriate assessments.
Section G: mobility, dressing, toileting, hygiene- Dependent;
Further review of the MDS revealed Resident #33 required total dependence of two + staff members for bed mobility and transfers.
Review of the Physician Orders dated July 2023 revealed orders for care, treatments, and services consistent with the resident's condition and diagnosis. Orders included, in part:
07/24/2023: Verbal order: X ray Left knee, Right ankle, Left ankle-2 views, Posterior and Anterior.
Review of the Care Plan for Resident #33 revealed the following, in part:
Problem Onset: 08/07/2019
Resident needs total assist with ADL's/Transfers; Resident uses a wheelchair for mobility, and a Hoyer lift x 3 person assist to get out of bed.
Goal Date: Resident will have needs met by next review date 10/18/2023.
Interventions, in part: Three person assist with all transfers from bed to Geri Chair. Make sure there is two staff members to side of scale and one to rear of Geri Chair for safe transfers.
On 07/25/2023 at 10:37 a.m., an interview was conducted with S19CNA and S21CNA. When asked about the incident on 07/24/2023 during the Hoyer transfer for Resident #33, S19CNA confirmed that she did not verify the resident's Geri chair was locked, and when she proceeded to put her in the Geri chair, the Geri chair moved. S19CNA stated the lift did not tilt over, but the lift pad did swing outward and scared the resident. S19CNA stated she and S21CNA lowered the resident down to the floor. S19CNA confirmed she should have locked the Geri chair and did not, which was an accident hazard. She confirmed Resident #33 was a 2 person transfer with Hoyer.
On 07/25/2023 at 11:00 a.m., an interview was conducted with S12LPN. She stated Resident #33 required 2+ person staff assist with mechanical lift transfers. She stated all Geri chairs should be locked during transfers to prevent accident hazards.
On 07/25/2023 at 11:25 a.m., an interview was conducted with S3ADON. She confirmed she was aware of the incident on 07/24/2023 in which Resident #33's Geri chair was not locked, and she was lowered to the floor during a Hoyer transfer by S19CNA and S21CNA. She verified this was an accident hazard for Resident #33.
On 07/25/2023 at 3:10 p.m., an interview was conducted with S4QARN. She confirmed Resident #33's Hoyer transfer incidents reported on 03/15/2023 and 07/24/2023. She also confirmed Resident #33's Geri chair was not locked during the transfer on 07/24/2023, performed by S19CNA and S21CNA, and should have been. She confirmed this was an accident hazard for Resident #33.
On 07/27/2023 at 9:35 a.m., an interview was conducted with S26MDS. She confirmed she had updated Resident #33's care plan with Problem Onset date 08/07/2019, Goal date of 10/18/2023, which stated Resident needs total assistance with ADL's/transfers. Resident uses a wheelchair for main mobility and a Hoyer lift x 3 person assist to get out of bed., after the 07/24/2023 Hoyer incident when her Geri chair was not locked, and should have been.
On 07/26/2023 at 11:20 a.m., an interview was conducted with S2DON. S2DON confirmed she was aware S19CNA and S21CNA had transferred Resident #33 on 07/24/2023. She also confirmed S19CNA and S21CNA should have locked Resident #33's Geri chair during the Hoyer transfer and did not, and this was an accident hazard.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident with an indwelling catheter recei...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections. The facility failed to ensure 1 (#51) of 2 (#51, #66) residents reviewed for indwelling urinary catheters did not have the urinary drainage bag and tubing on the floor.
Findings:
Review of the facility's policy titled, Indwelling Catheter Use and Removal revealed the following, in part:
Policy:
It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice.
Compliance Guidelines:
4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies that include but are not limited to:
d. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures
Review of Resident #51's Clinical Record revealed the resident was admitted to the facility on [DATE] with a readmission date to the facility on [DATE]. Resident #51 had diagnoses which included Penoscrotal Hypospadias, Paraplegia and Neurogenic Bladder.
Review of Resident #51's Physician Orders dated July 2023 revealed the following, in part:
Suprapubic catheter to bedside drainage and change suprapubic catheter every month between the 15th-20th and PRN.
Review of Resident #51's admission MDS with an ARD of 07/06/2023 revealed the following, in part:
Indwelling catheter: checked
An observation was made of Resident #51 sitting in his geri-chair on 07/24/2023 at 11:30 a.m. Resident #51's urinary catheter drainage bag was lying on the floor and the drainage tubing was touching the floor.
An observation was made of Resident #51 lying in bed on 07/25/2023 at 11:04 a.m. with S22CNA present. Resident #51's urinary catheter drainage bag was lying on the floor with the drainage tubing touching the floor. S22CNA verified Resident #51's urinary catheter drainage bag was lying on the floor with the drainage tubing touching the floor. S22CNA confirmed the urinary catheter drainage bag and drainage tubing should not touch the floor.
An observation was made of Resident #51 on 07/25/2023 at 11:09 a.m. with S14LPN. S14LPN verified Resident #51's urinary catheter drainage bag was lying on the floor with the drainage tubing touching the floor. S14LPN confirmed the catheter bag should not touch the floor to prevent urinary tract infections.
An interview was conducted with S2DON on 07/26/2023 at 12:50 p.m. S2DON confirmed Resident #51's urinary catheter drainage bag and drainage tubing should never touch the floor for urinary tract infection prevention. She confirmed the urinary drainage bag should be hung below the bladder from the bed and/or geri-chair with the drainage tubing off of the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash compactor.
Findings:
On 07/24/2023 at 9:10 a.m., an observation was m...
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Based on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash compactor.
Findings:
On 07/24/2023 at 9:10 a.m., an observation was made of the dumpster area outside the facility with S5DM. The following was observed:
There were approximately 2 pairs of disposable gloves, 3 straw wrappers and other unidentifiable paper items scattered on the ground all around the outdoor trash compactor. Six bags of trash noted on the ground beside and partially underneath the outdoor trash compactor. Three of the six bags were torn open with the trash exposed.
On 07/24/2023 at 9:11 a.m., an interview was conducted with S5DM. She confirmed the above observations and stated the trash should not be on the ground. She stated S9MS was responsible for cleaning around the outdoor trash compactor.
On 07/24/2023 at 9:20 a.m., an observation was made of the dumpster area outside the facility with S9MS. He confirmed the above observations and stated the trash should not be on the ground. He stated he was responsible for ensuring the dumpster area was clean on weekdays. He stated no staff was responsible for checking the dumpster area on the weekends. He was observed opening the outdoor trash compactor and stated there was room for the trash that was on the ground.
On 07/24/2023 at 10:50 a.m., an observation was made of the dumpster area outside the facility. There were approximately 2 pairs of disposable gloves, 3 straw wrappers and other unidentifiable paper items scattered on the ground all around the outdoor trash compactor. Six bags of trash noted on the ground beside and partially underneath the outdoor trash compactor. Three of the six bags were torn open with the trash exposed.
On 07/26/2023 at 10:15 a.m., an interview was conducted with S1ADM. She stated S9MS was responsible for keeping the dumpster area clean and free of debris during the week. She stated housekeeping staff were responsible for keeping the dumpster area clean and free of debris on the weekends. She was notified of the above observations on 07/24/2023 of the dumpster area. She said S5DM and S9MS made her aware of these observations and the dumpster area should have been clean and free of trash on the ground.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays. This had the potential to affect 97 Residents residing in the facility.
Findings:
Review of ...
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Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays. This had the potential to affect 97 Residents residing in the facility.
Findings:
Review of the facility's policy titled, Resident Right to Privacy in Communication revealed the following:
Policy: It is the policy of this facility to support and facilitate a resident's right to privacy in communications with individuals and entities within and external to the facility.
Definitions: Promptly means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service
Policy Explanation and Compliance Guidelines:
2. The social service designee, or another designated staff member, will ensure each resident receives any mail addressed to that particular resident promptly.
On 07/24/2023 at 1:20 p.m., during the Resident Council Meeting Resident's #20, #55, and #59 voiced concerns of not receiving mail on Saturdays. Resident #59 stated the residents did not receive mail on Saturdays because S8AD did not work on the weekends.
On 07/24/2023 at 1:30 p.m., an interview was conducted with S8AD. She stated she delivered mail to the residents Monday through Friday. She stated mail was delivered to S10R on Saturdays. She stated she was not sure who was responsible for delivering the residents their mail on Saturdays.
On 07/24/2023 at 1:35 p.m., an interview was conducted with S10R. She verified she worked on Saturdays and the mail was delivered directly to her at the front door. She stated she did not deliver the mail to the residents on Saturdays and locked it up in the Human Resources office until it was delivered to the residents on Mondays.
On 07/24/2023 at 2:05 p.m., an interview was conducted with S2DON. She stated Monday through Friday, S8AD was responsible for delivering the residents their mail. She stated on Saturdays the mail was delivered to S10R. She stated she did not know what S10R did with the mail once she received it but S10R could not deliver the mail until it was sorted. She confirmed mail was not delivered to the residents on Saturdays.
On 07/26/2023 at 10:20 a.m., an interview was conducted with S1ADM. She stated S8AD was responsible for distributing the resident's mail Monday through Friday. She stated on the weekends there was no designated staff member to ensure residents received their mail on Saturdays.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement a person-centered plan of care by failing...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement a person-centered plan of care by failing to administer Oxygen as ordered for 1 (#248) of 2 (#61 and #248) residents reviewed with Oxygen.
Findings:
Review of Resident #248's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses which included Cerebral Infarction, Type 2 Diabetes Mellitus, Chronic Systolic Heart Failure, Unspecified Atrial Fibrillation, and Cardiomyopathy.
Review of Resident #248's Physician Orders dated July 2023 revealed the following, in part:
(Start date: 06/29/2023) Oxygen continuous at 2L per nasal cannula
Review of Resident #248's admission MDS with an ARD of 07/10/2023 revealed she had a BIMS of 15, which indicated she was cognitively intact.
Review of Resident #248's Current Care Plan revealed the following, in part:
Problem: I require Oxygen therapy
Approaches: Administer my Oxygen as ordered
Review of Resident #248's MAR dated June 2023 through July 2023 revealed the following, in part:
Oxygen continuous at 2L per nasal cannula with a check mark and initials on the following dates and times, which indicated it was administered:
06/29/2023 at 9:00 p.m.;
06/30/2023 through 07/24/2023 at 5:00 a.m., 1:00 p.m., and 9:00 p.m.; and
07/25/2023 at 5:00 a.m. and 1:00 p.m.
An observation was made of Resident #248 on 07/24/23 at 1:11 p.m. She was not receiving Oxygen.
An observation was made of Resident #248 on 07/25/2023 at 9:56 a.m. She was not receiving Oxygen.
An observation was made of Resident #248 on 07/25/2023 at 12:57 p.m. She was not receiving Oxygen.
An interview was conducted with Resident #248 on 07/25/2023 at 12:58 p.m. She stated she was supposed to wear Oxygen but she had not had any since she admitted to the facility.
An interview was conducted with S16LPN on 07/25/2023 at 1:01 p.m. She stated Resident #248 was not supposed to be on Oxygen and she had never been on Oxygen. She reviewed Resident #248's medical record at that time and confirmed she had an order for continuous Oxygen. She confirmed Resident #248's continuous Oxygen had been documented as being administered every shift for all of July 2023. She confirmed she documented continuous Oxygen as being administered today, and Resident #248 had not received it.
An observation was made of Resident #248 on 07/25/2023 at 1:17 p.m. with S16LPN present. S16LPN confirmed Resident #248 did not have Oxygen in use and the Physician's Order was for continuous Oxygen at 2L/min.
An interview was conducted with S17CNA on 07/25/2023 at 1:26 p.m. She stated she frequently provided care for Resident #248. She stated Resident #248 had never worn Oxygen since she admitted to the facility.
An interview was conducted with S4QARN on 07/26/2023 at 10:10 a.m. She confirmed Resident #248 had an order for continuous Oxygen. She stated the nurses should have followed the order and should not have documented administration of continuous Oxygen if she was not receiving it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to develop procedures to ensure 4 (#19, #67, #87 and #149) of 5 (#19, #61, #67, #87 and #149) resident's records had documentation indicating...
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Based on interviews and record review, the facility failed to develop procedures to ensure 4 (#19, #67, #87 and #149) of 5 (#19, #61, #67, #87 and #149) resident's records had documentation indicating:
1. Residents or resident representatives received education regarding the benefits and potential side effects of Pneumococcal and Influenza immunization; and
2. Resident's either received the Pneumococcal and Influenza immunization or did not receive the Pneumococcal and Influenza immunization due to medical contraindication or refusal.
Findings:
Review of the facility's Pneumococcal Vaccine policy revealed the following, in part:
12. The resident's medical record shall include documentation that indicates at a minimum, the following:
a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization.
b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal.
Review of the facility's Influenza Vaccination policy revealed the following, in part:
5. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination.
9. The residents medical record will include documentation that the resident and/or the residents representative was provided education regarding the benefits and potential side effects of immunization and that the resident received or did not receive the immunization due to medical contraindication or refusal.
Review of Resident #19's clinical record revealed no documentation on provided education regarding benefits and side effects of Pneumococcal and Influenza vaccine. Further review revealed no documentation of Pneumococcal or Influenza immunization status.
Review of Resident #67's clinical record revealed no documentation on provided education regarding benefits and side effects of Pneumococcal and Influenza vaccine. Further review revealed no documentation of Pneumococcal or Influenza immunization status.
Review of Resident #87's clinical record revealed no documentation on provided education regarding benefits and side effects of Pneumococcal and Influenza vaccine. Further review revealed no documentation of Pneumococcal or Influenza immunization status.
Review of Resident #149's clinical record revealed no documentation on provided education regarding benefits and side effects of Pneumococcal and Influenza vaccine. Further review revealed no documentation of Pneumococcal or Influenza immunization status.
An interview was conducted on 07/26/2023 at 3:00 p.m. with S3ADON. She said she was unable to provide documentation of vaccination status of the residents listed above. She said she was responsible for ensuring accurate documentation of the resident's education and vaccination status.
An interview was conducted on 07/26/2023 at 3:10 p.m. with S1ADM. She reviewed the binder containing resident Pneumococcal and Influenza vaccination documentation. She confirmed the binder was unorganized and missing documentation regarding Pneumonia and Influenza vaccinations of the residents.
Apr 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. The facility failed to ensure Physician Orders for catheter care and monthly catheter changes were implemented for 1 (#4) of 5 (#1, #2, #3, #4, and #5) residents reviewed with catheters.
Findings:
Review of the facility's policy titled, Catheter Care revealed the following, in part:
Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.
Policy Explanation:
Catheter care will be performed daily and as needed by nursing personnel.
Review of the Clinical Record for Resident #4 revealed he was admitted to the facility on [DATE] with a urinary catheter.
Review of the Physician Orders for Resident #4 from March 2023 to April 2023 revealed no orders pertaining to his urinary catheter.
Review of the Physician Discharge Orders for Resident #4 dated 03/21/2023 from a hospital revealed the following, in part:
Additional Orders:
Other: .Urinary Catheter Care every shift, insertion date 02/20/2023 .
Review of the current Care Plan for Resident #4 revealed the following, in part:
Problem: I use an indwelling catheter
Approaches: Catheter care for me every shift
Review of the Nurses Notes for Resident #4 from March 2023 to April 2023 revealed, in part, he admitted to the facility with a urinary catheter. Further review revealed no documentation of urinary catheter care or urinary catheter changes.
Review of the MAR for Resident #4 dated March 2023 to April 2023 revealed, in part, no documentation pertaining to his urinary catheter.
An observation was made of Resident #4 on 04/03/2023 at 10:05 a.m. He had a urinary catheter with a drainage bag on the left side of his bed.
An observation was made of Resident #4 on 04/03/2023 at 1:26 p.m. He had a urinary catheter with a drainage bag on the left side of his bed.
An interview was conducted with S5CNA on 04/03/2023 at 1:28 p.m. She stated Resident #4 had been a resident at the facility for a couple weeks and she had been assigned to him since he admitted . She stated Resident #4 has had a urinary catheter since he admitted to the facility. She stated the nurses performed daily catheter care.
An interview was conducted with S2LPN on 04/03/2023 at 1:41 p.m. She confirmed she was assigned to Resident #4. She stated today was her first day to work with Resident #4. She stated she did not think Resident #4 had a urinary catheter. She confirmed there were not any catheter care orders or catheter change orders for Resident #4. She stated the nurse assigned to Resident #4 was responsible for catheter care and catheter changes.
An observation was made of Resident #4 on 04/03/2023 at 1:43 p.m. with S2LPN present. An interview was conducted with S2LPN at that time. She confirmed Resident #4 had a urinary catheter in place, and she was unaware he had a catheter.
An interview was conducted with S3LPN on 04/04/2023 at 11:06 a.m. She stated the nurses were responsible for performing catheter care daily, and it populated on the resident's MAR.
An interview was conducted with S1DON on 04/03/2023 at 1:53 p.m. She stated urinary catheter changes were completed monthly and catheter care was completed daily by the nurses. She confirmed Resident #4 did not have any Physician Orders related to his urinary catheter. She confirmed the floor nurse should have been aware Resident #4 had a urinary catheter. She confirmed there was no documentation in Resident #4's Clinical Record pertaining to urinary catheter care or urinary catheter changes. She stated if his catheter had been changed since he admitted to the facility, it should have been documented and it was not. She confirmed the discharge orders revealed Resident #4's urinary catheter was inserted on 02/20/2023 and should have been changed monthly. She stated S4MRLPN was responsible for inputting residents' orders on admission.
An interview was conducted with S4MRLPN on 04/03/2023 at 3:14 p.m. She stated urinary catheters had a fixed order set she implemented on admission. She stated the orders included urinary catheter drainage bag to bedside draining, cleanse urinary catheter daily, change catheter strap every Wednesday, and change urinary catheter every month and as needed. She confirmed Resident #4 did not have the urinary catheter protocol orders prior to today and should have.
An interview was conducted with S6NP on 04/03/2023 at 3:25 p.m. He confirmed Resident #4 had a urinary catheter. He stated the protocol for when a resident admitted with a urinary catheter was to initiate monthly catheter changes and daily catheter care. He confirmed he was notified today that the protocol was not initiated for Resident #4. He further confirmed the documentation revealed Resident #4's catheter had not been changed since 02/20/2023 and should have. He stated he gave orders for the facility to change the urinary catheter today.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
Concerns
- • 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (35/100). Below average facility with significant concerns.
- • 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Capitol House Nursing And Rehab Center's CMS Rating?
CMS assigns Capitol House Nursing and Rehab Center an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Capitol House Nursing And Rehab Center Staffed?
CMS rates Capitol House Nursing and Rehab Center's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 62%, which is 15 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Capitol House Nursing And Rehab Center?
State health inspectors documented 26 deficiencies at Capitol House Nursing and Rehab Center during 2023 to 2025. These included: 26 with potential for harm.
Who Owns and Operates Capitol House Nursing And Rehab Center?
Capitol House Nursing and Rehab Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 132 certified beds and approximately 93 residents (about 70% occupancy), it is a mid-sized facility located in Baton Rouge, Louisiana.
How Does Capitol House Nursing And Rehab Center Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Capitol House Nursing and Rehab Center's overall rating (1 stars) is below the state average of 2.4, staff turnover (62%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Capitol House Nursing And Rehab Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Capitol House Nursing And Rehab Center Safe?
Based on CMS inspection data, Capitol House Nursing and Rehab Center has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Capitol House Nursing And Rehab Center Stick Around?
Staff turnover at Capitol House Nursing and Rehab Center is high. At 62%, the facility is 15 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Capitol House Nursing And Rehab Center Ever Fined?
Capitol House Nursing and Rehab Center has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Capitol House Nursing And Rehab Center on Any Federal Watch List?
Capitol House Nursing and Rehab Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.