Capital Oaks Nursing & Rehabilitation Center LLC

In the surveyor’s words

From the most serious findings on record at Capital Oaks Nursing & Rehabilitation Center LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Feb 7, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Feb 7, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF697Feb 7, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Feb 17, 2023

  Based on interviews and record reviews, the facility failed to ensure there was adequate supervision and monitoring for 1 (#47) of 4 (#21, #47, #74, and #83) residents who was assessed as an elopement risk. This deficient practice resulted in an immediate jeopardy situation on 02/12/2023 at 2:44 p.m., when Resident #47, who had a BIMS of 3, indicating she was severely cognitively impaired, was taken out of Unit a to attend a parade by S10CNA. Resident #47 had diagnoses, which included Dementia and Memory Deficit following Cerebrovascular Disease. Additionally, Resident #47 was assessed as being at high risk for elopement. Resident #47 wandered from the facility unnoticed by staff. Resident #47 was found on 02/12/2023 at 10:00 p.m. […]

• Actual harm, isolatedF600Feb 21, 2024

  Based 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. […]