Capital Oaks Nursing & Rehabilitation Center LLC

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were offered a therapeutic diet when the health care provider ordered a nutritional supplement for 2 (#18 and #96) of 5 residents reviewed for nutrition.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident assessments accurately reflected the residents' status. The facility failed to ensure staff accurately coded: 1. The correct number of days insulin injections were received for 1 of 1 (#42) resident reviewed for insulin; and 2. Level II PASARR (Preadmission Screening and Resident Review) for 4 (#9, #44, #53, and #55) of 8 (#8, #9, #31, #44, #53, #55, #74, and #79) residents reviewed for PASARR.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan. The facility failed to: 1. Ensure a care plan was comprehensive and individualized for a medical diagnosis of Diarrhea for 1 ( #40) of 25 Resident's care plans reviewed; 2. Ensure a care plan was developed for a Level II PASRR(Preadmission Screening and Resident Review) for 1 (#53) of 6 (#8, #31, #44 #53, #74, #79) residents reviewed for PASRR; and 3. Ensure a care plan was comprehensive and individualized for behaviors of refusing monthly weights for 1 (#74) of 3 (#22, #52, and #74) Residents reviewed for nutrition.

Inspectors wroteBased on record review and interviews, the facility failed to have a policy identifying circumstances when the loss or damage of dentures was the facility's responsibility. This deficient practice had the potential to affect any of the 112 residents residing in the facility who wore dentures.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain complete and accurate records in accordance with accepted professional standards and practices for 4 (#9, #22, #53, and #89) of 25 sampled residents reviewed for accurate documentation. The facility failed to accurately document: 1. Completion of wound care for Residents #9, #22, and #53; and 2. Administration of Enteral Feedings for Resident #89.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 2 (#31 and #79) of 5 (#8, #31, #53, #74, and #79) sampled residents reviewed for PASRR Level II.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of infection for 1 of 1 (#55) resident reviewed with a urinary catheter. The facility failed to ensure staff performed proper hand hygiene and glove use while providing catheter care for Resident #55.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's physician was notified of significant changes that required treatment to be altered for 1(#1) of 3 (#1, #2, and #3) residents reviewed for falls with injury. The facility failed to ensure nursing staff notified the physician when Resident #1 fell, had new onset complaints of pain, and required increased assistance with transfer. The deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively impaired resident, beginning on 01/02/2025 at 5:00 a.m., when S7CNA failed to report Resident #1 fell during transfer, hitting his wheelchair. From 01/02/2025 at 5:00 a.m. through 01/03/2025 at 7:30 a.m., Resident #1 had multiple complaints of new onset pain and required increased assistance with transfers from staff. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident's right to be free from neglect for 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to ensure Resident #1 received needed services and treatment when CNA staff neglected to report a fall, which resulted in a left femur fracture. The deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively impaired resident, beginning on 01/02/2025 at 5:00 a.m., when S7CNA failed to report Resident #1 fell during transfer, hitting his wheelchair. From 01/02/2025 at 5:00 a.m. through 01/03/2025 at 7:30 a.m., Resident #1 had multiple complaints of new onset pain and required increased assistance with transfers from staff. Staff did not report the pain or decline in status to the physician during this time for new interventions or treatment. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide pain management consistent with professional standards of practice for a cognitively impaired resident, following a fall, for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for pain. Nursing staff failed to assess and treat Resident #1 after multiple complaints of new onset pain. The deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively impaired resident, beginning on 01/02/2025 at 5:00 a.m., when S7CNA failed to report Resident #1 fell during transfer, hitting his wheelchair. From 01/02/2025 at 5:00 a.m. through 01/03/2025 at 7:30 a.m., Resident #1 had multiple complaints of new onset pain and required increased assistance with transfers from staff. Staff did not report the pain or decline in status to the physician during this time for new interventions or treatment. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure alleged violations involving neglect were reported immediately to the Administrator and a law enforcement entity within 2 hours after the allegations of neglect were made to the state agency for 1 (Resident #1) of 3 (Resident #1, #2, and #3) residents reviewed for neglect.

Inspectors wroteBased on interviews, and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident for 1 (#85) of 32 residents reviewed for abuse during the initial pool. The facility failed to protect Resident #85 from physical abuse by Resident #22. This deficient practice resulted in an actual harm situation on 02/12/2024 at 3:41 a.m. when Resident #22, pulled Resident #85, a moderately cognitively impaired resident, out of her bed and began punching her in the head and face. At 3:41 a.m., S10LPN entered the residents' room and found Resident #85 on the floor with Resident #22 holding Resident #85's right hand while she punched her in the head and face. S10LPN heard Resident #85 yell, Please help me. She's gonna kill me. The residents were then separated. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents had a safe, functional, sanitary and comfortable environment for 7 (Room a, Room b, Room c, Room d, Room e, Room f, Room g) of 32 resident rooms observed in the initial pool. The facility failed to ensure: 1. Floors were intact and free from missing planks in rooms a, c, e; 2. Floors were free of stains or glue/residue in room a, b; 3. Bathrooms were free of missing cabinet doors in room a; 4. Bathrooms had working light bulbs and light bulb covers in room d; 5. Closet doors properly functioned and remained on track in rooms f, g; 6. Toilets functioned properly, remained free from a constant loud noise in room f and the toilet seat was not cracked in room d; 7. Bathroom sink handles were secure and free from leaking in room c; 8. Bed hand rails were securely fastened and sturdy in room e; 9. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure: 1. Accuchecks were obtained and insulin was administered before meals as ordered for 1 (#47) of 3 (#47, #75, and #100) residents reviewed for insulin administration and 2. Nursing staff accurately documented the trimming of fingernails for 1 (#74) of 3 (#41, #74, and #109) residents reviewed for ADLs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#74) of 3 (#41, #74 and #109) residents reviewed for ADL's. The facility failed to trim fingernails for Resident #74.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% for 2 (#34 and #47) of 6 (#34, #35, #47, #75, #100, and #107) residents observed during medication administration. A total of 27 opportunities were observed with 2 medication errors, which resulted in a medication error rate of 7.41%. The facility failed to ensure: 1. Resident #34's Voltaren Gel was not omitted; and 2. Resident #47's Insulin was administered before meals as ordered.