Capital Oaks Nursing & Rehabilitation Center Llc

F-F580

Review of the facility's policy, Abuse/Neglect Policy Statement, dated 12/11/2018 revealed the following, in part:

The facility will not condone any form of resident neglect Each resident has the right to be free from neglect.

Abuse/Neglect Reporting Definitions

9. Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish .

Identification: Possible indicators of Potential Abuse and Neglect

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 17 195635 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195635 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Capital Oaks Nursing & Rehabilitation Center LLC 4100 North Blvd Baton Rouge, LA 70806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 1. Injuries of unknown origin

Level of Harm - Immediate 3. Changes in the behavior pattern of the resident jeopardy to resident health or safety 6. New onset of physical concern (pain)

Residents Affected - Few 23. Complaints of pain or injury that have not been addressed by facility staff

26. Medical conditions that have not been addressed by nursing personnel .evaluations based on the individual's needs

27. Inability of the resident to access medical personnel

Review of the facility's undated policy, Falls, revealed the following, in part:

Policy: To provide emergency care.

Procedure

1. Resident will not be moved until a Licensed Nurse has ascertained resident's condition.

2. Assess resident for any abnormalities: i.e.,

a. deformed, discolored or painful body parts

c. Vitals

3. Ascertain extent and type of injury.

4. Make resident as comfortable as condition permits

5. Notify physician for further orders.

Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE REDACTED] with diagnoses, which included, in part, the following: Muscle Wasting and Atrophy, Age Related Osteoporosis, Dementia, Alzheimer's Disease, Aphasia, and Cognitive Communication Deficit. Further review revealed Resident #1 was diagnosed with a Left Femur Fracture resulting from a fall on 01/02/2025.

Review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/2024, revealed a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. Further review revealed no indication Resident #1 had pain upon assessment completion.

Review of Resident #1's current Care Plan revealed the resident had impaired cognition and communication related to Alzheimer's Disease and Expressive Aphasia. Further review of Resident #1's Care Plan revealed

the following interventions:

Start date: 01/02/2025 - X-Ray of L hip/pelvis and knee

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 17 195635 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195635 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Capital Oaks Nursing & Rehabilitation Center LLC 4100 North Blvd Baton Rouge, LA 70806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Start date: 01/02/2025 - Send to local hospital emergency room for eval

Level of Harm - Immediate Review of Resident #1's January 2025 Medication Administration Record (MAR) revealed the following: jeopardy to resident health or safety X-ray left hip, femur, and knee for complaint of increased of pain to area for left hip/leg pain - Start date 01/03/2025 Residents Affected - Few

Review of Resident #1's Imaging Results, dated 01/03/2025, revealed, in part, the following: a CT without contrast of the left hip was performed which showed a Displaced comminuted intertrochanteric femur fracture with surrounding soft tissues swelling. Fracture planes extend through the greater and lesser tuberosities and mild degenerative change.

Review of Resident #1's local hospital record notes revealed an admitted [DATE REDACTED] at 2:38 p.m. Resident's chief complaint was hip pain with a pain score of 4. Resident was administered 4 mg of Morphine at 5:00 p. m. Resident was admitted to the hospital on the same day with a Left femur fracture. Orthopedics was consulted and surgery was performed on 01/04/2025 to surgically repair a Left Femur Fracture.

On 01/30/2025 at 12:37 p.m., an interview was conducted with S11SW. She stated she was responsible for completing BIMS assessments. She stated Resident #1 was able to respond to limited questions. She stated

he was oriented to person only and could not identify the month and year. She stated he was not able to recall events that occurred 5 minutes ago.

On 01/29/2025 at 1:38 p.m., an interview was conducted with S7CNA. She stated, on 01/02/2025 at approximately 5:00 a.m., she transferred Resident #1 in his room. She explained during the transfer, the resident began to struggle and she had to lower the resident to the ground. She stated, as he was being lowered he hit his left side on the wheelchair. She stated she called S12CNA into the room and they picked

the resident up off the floor placing him back in his wheelchair. She stated after getting the resident into his wheelchair, he did not complain of pain or show nonverbal signs of pain, and there were no visible injuries.

She stated Resident #1 did fall to the floor and she did not report the fall to the nurse or her supervisor. She stated later that day, at 1:15 p.m., she transferred the resident into bed and the resident complained of pain.

She stated she reported the pain to S4LPN, but did not report the resident fell .

On 01/30/2025 at 8:35 a.m., an interview was conducted with S12CNA. She stated on the morning of 01/02/2025, S7CNA asked for help with transferring Resident #1. She stated when she walked into the room Resident #1 was on the floor in front of the wheelchair with his legs straight out in front of him. She stated he did not complain of any pain. She stated she helped S7CNA move him to his wheelchair and went back to her assigned unit. She did not know how resident ended up on the floor and she did not report the resident was found on the floor.

On 01/29/2025 at 2:17 p.m., an interview was conducted with S8CNA. She stated around lunch time on 01/02/2025, she assisted S7CNA with transferring Resident #1 from his bed to the wheelchair. She stated,

during the transfer, Resident #1 cried out in pain when his left leg was moved. She stated she was not aware of Resident #1 having a fall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 17 195635 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195635 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Capital Oaks Nursing & Rehabilitation Center LLC 4100 North Blvd Baton Rouge, LA 70806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 01/29/2025 at 2:43 p.m., an interview was conducted with S9CNA. She stated on 01/02/2025 at approximately 2:00 p.m., she went into Resident #1's room to change his brief. She stated the resident had Level of Harm - Immediate been lying on his right side and did not want to roll to his back. She stated she asked Resident #1 what was jeopardy to resident health or wrong and he responded my leg. She stated she continued to change the resident's brief, sat him up on the safety side of his bed, and transferred him into his wheelchair. She stated prior to the Left Femur Fracture, Resident #1 was able to stand and pivot for transfers, but on this day he did not stand on his own. She stated she had Residents Affected - Few to extensively assist him into the wheelchair, and this was not his normal. She stated she was not aware of Resident #1 having a fall.

On 01/29/2025 at 3:45 p.m., an interview was conducted with S5LPN. She stated on 01/02/2025 she worked

the evening shift on Resident #1's hall. She stated she did not receive a report or a fall regarding Resident #1 during her shift on 01/02/2025 by the CNA staff. She stated before his Left Femur Fracture, Resident #1 was able to stand and pivot with transfers and did not normally complain of pain.

On 01/30/2025 at 8:52 a.m., an interview was conducted with S10CNA. She stated on 01/03/2025, she and S7CNA were bringing Resident #1 back to his room via wheelchair, when Resident #1 complained of leg pain. She stated before his injury, Resident #1 was able to get himself out of his wheelchair and onto the sofa without assistance. She stated she was not aware of Resident #1 having a fall.

On 01/30/2025 at 12:24 p.m., an interview was conducted with S4LPN. She stated at approximately 1:00 p. m. on 01/02/2025, S7CNA notified her Resident #1 had complained of pain. She stated the CNA did not notify her that the resident had fallen earlier in the day. She stated on 01/03/2025 at approximately 7:00 a.m. Resident #1 was in his wheelchair being pushed through the dining room. She stated she and S5LPN overheard S10CNA state Resident #1 could not stand on his leg and he had complained of pain. She stated

she and S5LPN completed an assessment on Resident #1 by moving his left leg. She stated when the left leg was moved, Resident #1 grimaced. She stated the charge nurse and Nurse Practitioner (NP) were notified, x-ray was ordered, and Tylenol was given. She stated Resident #1 was oriented to self only. She stated due to his cognitive impairment, he was only capable of reporting pain he currently felt, not pain from

an earlier time. She stated Resident #1 did not normally complain of pain and this was a new complaint for him.

On 01/30/2025 at 12:29 p.m., an interview was conducted with S3RN. She stated on 01/02/2025 S8CNA called the nurse's station and informed her of Resident #1's complaint of pain but did not report the resident had fallen earlier in the day. S3RN stated Resident #1 was oriented to self only and could not answer questions appropriately. She stated he would not be able to communicate pain unless he was feeling pain at that moment. She stated Resident #1 did not normally complain of pain. She stated a cognitively impaired resident's pain assessment would include the following; asking verbally, moving resident and observing for grimacing, and speaking with staff that reported the pain for more information. She stated she would expect

a reasonable person with a fracture to express pain with movement or manipulation.

On 01/30/2025 at 12:39 p.m., an interview was conducted with S2DON. She confirmed she was not aware Resident #1 had a fall on 01/02/2025. She stated a cognitively impaired resident's pain assessment would include the following: observing for grimaces and checking for limited range of motion. She stated Resident #1 would not be able to communicate pain unless he was currently experiencing pain. She stated if a resident had fallen to the floor, expressed pain, and no report of fall was made she would consider this neglect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 17 195635 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195635 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Capital Oaks Nursing & Rehabilitation Center LLC 4100 North Blvd Baton Rouge, LA 70806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 01/29/2025 at 3:00 p.m. an interview was conducted with S1ADM. He stated he was not aware Resident #1 had a fall to the floor on 01/02/2025. He stated a CNA withholding information about a resident's fall that Level of Harm - Immediate would delay necessary care would be classified as neglect. jeopardy to resident health or safety The surveyors confirmed the following had been initiated and/or implemented prior to exit:

Residents Affected - Few 1. All staff were in-serviced on resident pain and change of condition reporting (Conducted on 01/03/2025)

2. Nursing staff were in-serviced on proper transfers (Conducted on 01/03/2025)

3. All staff were in-serviced on abuse and neglect policies (Conducted on 01/06/2025) including different types of abuse and neglect and how they can occur in the facility and corporate policies identifying, preventing, and reporting abuse or neglect.

4. In-service conducted on incident and accident reporting including definitions and reinforcement of the need for immediate documentation and notification of supervisory staff.

5. Daily huddles performed with CNAs and nurses, randomly picking a section of the building and asking if any reported falls or if any issues of abuse/neglect have been reported. (Started 02/07/2025 and to continue for 2 weeks and randomly thereafter.

6. QA monitoring of one person assist transfers and assessment of pain and reporting of falls. An administrative nurse or designee will randomly monitor transfers 3 times a week for 6 weeks and monthly thereafter (Implemented on 01/06/2025).

7. Implementation of a questionnaire regarding abuse and neglect:

A questionnaire will be implemented randomly monitoring all staff members of their knowledge of abuse/neglect. Ten staff members will be randomly selected and questioned weekly for six weeks. The questionnaire will bring up specific types of abuse/neglect and if the staff members know and understand what they are. Random checks will continue after the initial six-week period to ensure continued compliance (Implemented on 02/06/2025)

8. Incident and accident Questionnaire - A questionnaire will be implemented randomly monitoring staff members for their knowledge of incident and accident reports. The questionnaire gives specific examples of what to do if a resident is on the floor and how to report those instances to administration (Implemented on 02/06/2025)

As of 02/07/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 17 195635 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195635 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Capital Oaks Nursing & Rehabilitation Center LLC 4100 North Blvd Baton Rouge, LA 70806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47546

Residents Affected - Few Based 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.

Findings:

Cross reference:

F-F600

Review of the facility's undated policy, Falls revealed the following, in part:

Policy: To provide emergency care.

Procedure

1. Resident will not be moved until a Licensed Nurse has ascertained resident's condition.

2. Assess resident for any abnormalities: i.e.,

a. deformed, discolored or painful body parts

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 195635 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195635 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Capital Oaks Nursing & Rehabilitation Center LLC 4100 North Blvd Baton Rouge, LA 70806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 c. Vitals

Level of Harm - Immediate 3. Ascertain extent and type of injury. jeopardy to resident health or safety 4. Make resident as comfortable as condition permits

Residents Affected - Few 5. Notify physician for further orders.

Review of the facility's undated policy, Accident/Incident Reports: Resident

Purpose: To provide appropriate follow-through on all accidents/incidents. To study the cause of accidents and incidents and to give guidance for corrective/preventive action.

Procecure:

1. Do not move the resident until a Licensed Practical Nurse evaluated the condition.

2. Notify the nurse in charge.

3. Licensed Nurse - .Complete a thorough head -to-toe assessment of the resident for possible injury, including range of motion.

6. Make the resident comfortable.

7. Notify the resident's physician-receive orders for follow-through.

10. Note the location and the time of the incident, and the exact circumstances of the incident.

Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE REDACTED] with diagnoses which included, in part, the following: Muscle Wasting and Atrophy, Age Related Osteoporosis, Dementia, Alzheimer's disease, Aphasia, and Cognitive Communication Deficit. Further review revealed Resident #1 was diagnosed with a Left Femur Fracture resulting from a fall on 01/02/2025.

Review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/2024, revealed a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. Further review revealed no indication Resident #1 had pain upon assessment completion.

Review of Resident #1's current Care Plan revealed the resident had impaired cognition and communication related to Alzheimer's Disease and expressive aphasia. Further review revealed the resident had chronic pain.

Review of Resident #1's January 2025 Medication Administration Record (MAR) revealed no documentation

the resident received medication for the treatment of pain until 01/03/2025 at approximately 7:30 a.m. when Resident #1 was administered Tylenol after S4LPN assessed him to find pain with movement of his left leg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 195635 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195635 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Capital Oaks Nursing & Rehabilitation Center LLC 4100 North Blvd Baton Rouge, LA 70806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Review of Resident #1's Imaging Results, dated 01/03/2025, revealed, in part, the following: a CT without contrast of the left hip was performed which showed a Displaced comminuted intertrochanteric femur fracture Level of Harm - Immediate with surrounding soft tissues swelling. Fracture planes extend through the greater and lesser tuberosities jeopardy to resident health or and mild degenerative change. safety

Review of Resident #1's local hospital record notes revealed an admitted [DATE REDACTED] at 2:38 p.m. Resident's Residents Affected - Few chief complaint was hip pain with a pain score of 4. Resident was administered 4 mg of Morphine at 5:00 p. m. Resident was admitted to the hospital on the same day with a Left femur fracture. Orthopedics was consulted and surgery was performed on 01/04/2025 to surgically repair a Left Femur Fracture.

On 1/30/2025 at 12:37 p.m., an interview was conducted with S11SW. She stated she was responsible for completing the BIMS assessments on residents. She stated Resident #1 was able to respond to limited questions. She stated he was oriented to person only and could not identify the month and year. She stated

he was not able to recall events that occurred 5 minutes ago.

On 01/30/2025 at 7:10 a.m., an interview was conducted with S6LPN. She stated at approximately 4:45 a.m.

on 01/02/2025, she heard Resident #1 yell from his room. She stated when she got to Resident #1's room he was dressed and sitting on the side of the bed. She stated S7CNA was in the room with the resident and S7CNA said everything was ok. She stated she asked Resident #1 if he was ok and the resident did not respond. She said she did not assess the resident at this time. She stated Resident #1 did not get up on the night of 01/02/2025 and slept. She further stated Resident #1 did not often complain of or show signs of pain.

She stated before his injury, Resident #1 was able to stand and would sometimes get into his wheelchair without assistance.

On 01/29/2025 at 1:38 p.m., an interview was conducted with S7CNA. She stated, on 01/02/2025 at approximately 5:00 a.m., she transferred Resident #1 in his room. She explained during the transfer, the resident began to struggle and she had to lower the resident to the ground. As he was being lowered he hit his left side on the wheelchair. She stated she called S12CNA into the room and picked the resident up off

the floor placing him back in his wheelchair. She stated after getting the resident into his wheelchair, he did not complain of pain or show nonverbal signs of pain, and there were no visible injuries. She stated she did not report the fall to the nurse or her supervisor. She stated later that day, at 1:15 p.m., she transferred the resident into bed and the resident complained of pain. She stated she reported the pain to S4LPN, but did not report the resident fell .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 195635 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195635 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Capital Oaks Nursing & Rehabilitation Center LLC 4100 North Blvd Baton Rouge, LA 70806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 On 01/30/2025 at 12:24 p.m., an interview was conducted with S4LPN. She stated at approximately 1:00 p. m. on 01/02/2025, S7CNA notified her Resident #1 had complained of pain. She confirmed she did not Level of Harm - Immediate complete a full pain assessment on Resident #1 on 01/02/2025 when the complaint of pain was reported to jeopardy to resident health or her. She stated on 01/03/2025 at approximately 7:00 a.m. Resident #1 was in his wheelchair being pushed safety through the dining room. She stated she and S5LPN overheard S10CNA state Resident #1 could not stand

on his leg and he had complained of pain. She stated at that time she and S5LPN completed an assessment Residents Affected - Few on Resident #1 by moving his left leg. She stated when the left leg was moved, Resident #1 grimaced. She stated the charge nurse and NP were notified, x-ray was ordered, and Tylenol was given. She stated Resident #1 was oriented to self only. She stated due to his cognitive impairment, he was only capable of reporting pain he currently felt, not pain from an earlier time. She stated Resident #1 did not normally complain of pain and this was a new complaint for him. She stated a reasonable person with a femur fracture would express pain with incontinent care. She stated a cognitively impaired resident's pain assessment would include the following; asking if they had pain, observe for pain indicators, such as grimacing, pulling away or favoring a certain area. She confirmed on 01/02/2025 she only asked the resident if he was in pain.

On 01/29/2025 at 2:17 p.m., an interview was conducted with S8CNA. She stated around lunch time on 01/02/2025, she assisted S7CNA with transferring Resident #1 from his bed to the wheelchair. She stated,

during the transfer, Resident #1 cried out in pain when his left leg was moved. She stated she notified S3RN, who then notified S4LPN about the resident's complaint of pain.

On 01/29/2025 at 2:43 p.m., an interview was conducted with S9CNA. She stated on 01/02/2025 at approximately 2:00 p.m., she went into Resident #1's room to change his brief. She stated the resident had been lying on his right side and did not want to roll to his back. She stated she asked Resident #1 what was wrong and he responded my leg. She stated she continued to change the resident's brief, sat him up on the side of his bed, and transferred him into his wheelchair. She stated prior to the left femur fracture, Resident #1 was able to stand and pivot for transfers, but on this day he did not stand on his own. She stated she had to extensively assist him into the wheelchair, and this was not his normal. She stated she notified S5LPN that Resident #1 had complained of pain.

On 01/29/2025 at 3:45 p.m., an interview was conducted with S5LPN. She stated on 01/02/2025 she worked

the evening shift on Resident #1's hall. She stated he did not complain of pain while he was up in his wheelchair, and did not appear to be in pain when she was in his room. She stated she did not receive a report of pain regarding Resident #1 during her shift on 01/02/2025. She stated on 01/03/2025, S9CNA reported the resident had pain. She stated before his left leg fracture, Resident #1 was able to stand and pivot with transfers and did not normally complain of pain.

On 01/30/2025 at 8:52 a.m., an interview was conducted with S10CNA. She stated on 01/03/2025 she and S7CNA were bringing Resident #1 back to his room via wheelchair with S8CNA, when Resident #1 complained of leg pain. She stated she reported this to S3RN. She stated before his injury, Resident #1 was able to get himself out of his wheelchair and onto the sofa without assistance.

On 01/30/2025 at 10:00 a.m. an interview was conducted with S13NP. S13NP stated she was not notified Resident #1 had a fall on 01/02/2025 and should have been. She further stated she had not been made aware of Resident #1's complaints of pain until 01/03/2025. She stated if she had known about the fall and subsequent complaints of pain she would have ordered an x-ray sooner or waited until she could assess the resident herself.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 195635 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195635 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Capital Oaks Nursing & Rehabilitation Center LLC 4100 North Blvd Baton Rouge, LA 70806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 On 01/30/2025 at 12:29 p.m., an interview was conducted with S3RN. She stated on 01/02/2025 S8CNA called the nurse's station and informed her of Resident #1's complaint of pain. She stated she informed Level of Harm - Immediate S4LPN within minutes. She stated S4LPN went to Resident #1's room, came back and reported to her jeopardy to resident health or Resident #1 denied pain. S3RN stated Resident #1 was oriented to self only and could not answer questions safety appropriately. She stated he would not be able to communicate pain unless he was feeling pain at that moment. She stated Resident #1 did not normally complain of pain. She stated CNA should have reported Residents Affected - Few that resident was having pain in leg while performing transfer or incontinent care. She stated a cognitively impaired resident's pain assessment would include the following; asking verbally, moving resident and observing for grimacing, and speaking with staff that reported the pain for more information. She stated she would expect a reasonable person with a fracture to express pain with movement or manipulation.

On 01/30/2025 at 12:39 p.m., an interview was conducted with S2DON. She stated a cognitively impaired resident's pain assessment would include the following: observing for grimaces and checking for limited range of motion. She stated the assessment would be based on who it was and based on the clinical presentation. She stated Resident #1 would not be able to communicate pain unless he was currently experiencing pain. She stated Resident #1 would not be able to communicate pain unless it was current. She further stated Resident #1 would not be able to communicate pain 5 minutes after it had occurred.

The surveyors confirmed the following had been initiated and/or implemented prior to exit:

1. All residents who were identified as cognitively impaired were assessed to see if they showed any signs or symptoms of pain. A thorough review of each of the cognitively impaired residents fall risk assessment was completed by the Clinical Care Coordinators.

2. All staff were trained by the Administrator, DON, or designee to report any observed or verbalized pain or any change of condition immediately to a nurse or an administrative team member. The nurse or an administrative nurse will follow the standing or PRN orders and will follow up with their MD (Started 01/03/2025).

3. All nurses were in-serviced to ensure a proper pain assessment was completed when a resident reports or shows any signs of pain to a staff member (Started 02/03/2025).

4. Monitoring was implemented to assess resident pain with interviews of a random sample of nurses 3 times

a week for 6 weeks and monthly thereafter including a specific section asking residents about pain during transfers (Started 01/30/2025).

5. Daily huddles with administrative staff in random facility sections asking nurses and CNAs about any

observations of pain or incidents that occurred during their shift. These huddles started on 02/07/2025 and will be conducted daily for 2 weeks, then monthly thereafter for 3 months.

As of 02/07/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 195635