Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baton Rouge Health Care Center during CMS and state inspections, most recent first.
A resident with a history of falls and moderate cognitive impairment had a call light that was not within reach, despite a care plan intervention to use the call light for assistance with transfers. Another resident, who was observed smoking on the smoking patio, was not identified on the smokers list and had no smoking-related care plan even though staff stated he was a safe smoker.
Failure to follow standing insulin orders and notify the provider of blood glucose readings over 400 affected two residents with Type 2 DM. One resident had a BG of 409 with no nurse note documenting provider notification, and another resident had multiple BG readings above 400, including 557, with no documentation that the MD or NP was notified. LPNs confirmed they did not notify the provider, and the NP and DON stated they expected notification when BG was over 400.
A facility failed to keep call lights within reach for two residents who were care planned to use them for assistance. One resident with CVA-related hemiplegia and moderate cognitive impairment had a call light hanging on the outlet and out of reach, while another resident with dementia, visual loss, and dependence for transfers had the call light attached to the bed and out of reach while seated in a Geri-chair. Staff, including an LPN, CNAs, and MDS staff, confirmed the call lights should have been within reach.
A resident who was totally dependent on staff for bathing did not have scheduled baths or refusals properly documented on multiple occasions. Staff interviews confirmed that baths were either given but not recorded, or refusals were not charted, resulting in incomplete ADL documentation.
A CNA in the facility failed to treat residents with dignity and respect, as reported by four residents. The residents described the CNA's behavior as rude, condescending, and rough during care. One resident reported an incident where the CNA refused to apply necessary cream, while another was upset over the CNA's stern communication regarding bathroom use. The facility's policy requires all residents to be treated with kindness and respect, which was not followed in these cases.
The facility failed to ensure call lights were within reach for two residents, both at risk for falls. One resident with cerebral infarction and hemiparesis was observed with the call light tied to the bed rail, out of reach. Another resident with similar conditions was also unable to reach the call light. Both a CNA and an LPN confirmed the call lights were not accessible, and the DON acknowledged the issue.
A resident's privacy was compromised during ADL care when staff failed to pull the privacy curtain, allowing the roommate to see the resident's unclothed body. Staff and administration confirmed the oversight, acknowledging the need for privacy measures.
A resident requiring two-person assistance and a mechanical lift for transfers was injured when a CNA attempted to transfer her alone without the lift. The resident, with a history of muscle weakness and heart failure, slid from her wheelchair and sustained fractures. The CNA was unaware of the resident's transfer needs, leading to the incident.
A facility failed to limit the duration of a PRN order for a psychotropic medication for a resident. The resident's record showed an order for Temazepam 7.5 mg for insomnia without a stop date or duration, contrary to regulations requiring PRN psychotropic medications to be limited to 14 days. The DON confirmed the oversight during an interview.
Care Plan Not Developed for Call Light Access and Smoking Status
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan when Resident #15's call light was not within reach. Resident #15 had diagnoses including cerebral infarction and hemiplegia and hemiparesis following a cerebrovascular accident. The quarterly MDS dated 09/03/2025 showed a BIMS of 12, indicating moderate cognitive impairment, and the resident required substantial assistance for transfers. The current care plan identified a history of falls and risk for injury related to falls and included an intervention to encourage use of the call light for assistance with transfers, but on 09/29/2025 the resident's call light was observed hanging on the outlet and not in reach. The resident stated he could not reach it, and an LPN later confirmed the call light was not in reach and should have been. The facility also failed to care plan Resident #71 as a smoker. Resident #71 had diagnoses including end stage renal disease, cerebral infarction, and chronic respiratory failure with hypoxia. The quarterly MDS dated 09/10/2025 showed a BIMS of 14, indicating cognitive intactness. The facility's smokers list did not identify Resident #71 as a smoker, and the current care plan contained no smoking-related care plan. However, on 09/29/2025 the resident was observed outside on the smoking patio smoking a cigarette. During interviews, two CNAs stated Resident #71 was a safe smoker, and the CC stated she was responsible for updating care plans and confirmed the resident was not care planned as a smoker until the evening before the interview, stating he should have been care planned for being a smoker before then.
Failure to Notify Provider of Critical Blood Glucose Readings
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality by not following standing physician orders and not notifying the physician or nurse practitioner when residents’ blood glucose readings were over 400. The facility’s standing blood glucose monitoring orders stated that if glucose was greater than 400, 10 units of Novolog/Humalog insulin should be given and the provider notified for additional orders. Review of the records showed Resident #7, who had Type 2 Diabetes Mellitus, had a blood glucose reading of 409 on 09/08/2025, with no documentation in the nurses’ notes that the doctor or nurse practitioner was notified. Resident #15, who also had Type 2 Diabetes Mellitus, had multiple blood glucose readings over 400 documented in the MAR, including 426, 447, 557, 466, 443, 428, 434, and 486. Review of the nurses’ notes showed no documentation that the doctor or nurse practitioner was notified on any of those dates. During interviews, S6LPN and S4LPN confirmed they did not notify the doctor for the elevated blood glucose readings and should have. S5NP stated she expected to be notified when a resident’s blood glucose was over 400, and S2DON stated the nurse practitioner should be notified and expected nurses to do so.
Call lights not kept within reach for two residents
Penalty
Summary
The facility failed to ensure resident call lights were within reach for 2 of 24 residents reviewed. The facility policy titled, Call Light/Call Pager Systems, stated the call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Resident #15, who was admitted with diagnoses including cerebral infarction and hemiplegia/hemiparesis following CVA, had a quarterly MDS showing a BIMS of 12 and required substantial assistance for transfers. The resident's care plan directed staff to encourage use of the call light for assistance with transfers, but on observation the call light was hanging on the outlet and not in reach; the resident pointed to it and stated he could not reach it. An LPN later confirmed the call light was not in reach and should have been. Resident #99, who was admitted with diagnoses including polyosteoarthritis, visual loss, pain, and dementia, had a quarterly MDS showing a BIMS of 4 and was dependent on staff for transfers. The resident's care plan directed staff to encourage use of the call light for assistance, but observations showed the resident sitting in a Geri-chair approximately 2 feet from the bed with the call light attached to the side of the bed and out of reach. An LPN confirmed the call light was not in reach and should have been. CNAs stated the resident used the call light for assistance and it should be in reach at all times, and the MDS staff member confirmed that if a resident was care planned to use the call light for assistance, it should be kept within the resident's reach.
Failure to Accurately Document Resident Bathing Activities
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's bathing activities, as required by accepted professional standards. A review of the clinical record for a resident with hemiplegia and hemiparesis following a cerebral infarction revealed that the resident was totally dependent on staff for bathing. The resident's care plan specified scheduled bath days, but the bath flowsheet showed missing documentation for three scheduled days. On one of these days, the assigned CNA confirmed the resident refused the bath but acknowledged she did not document the refusal. On the other two days, the responsible CNA stated she provided the baths but failed to document them. Interviews with the CNAs and the Director of Nursing confirmed that the baths or refusals were not recorded as required. The lack of documentation was verified by staff upon review of the bath flowsheet, and staff acknowledged that all baths given or refused should have been documented. The deficiency was identified through record review and staff interviews, which established that the facility did not maintain complete and accurate records of the resident's ADL care.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple reports of inappropriate behavior by a certified nursing assistant (CNA), identified as S8CNA. The facility's policy on resident rights mandates that all residents be treated with kindness, respect, and dignity, which was not adhered to in this case. Interviews and record reviews revealed that four residents experienced disrespectful and rough treatment from S8CNA, which compromised their quality of life. Resident #1, with an intact cognitive ability as indicated by a BIMS score of 14, reported that S8CNA spoke to her in a rude and condescending tone and handled her roughly during care. Similarly, Resident #21, with a moderately intact cognitive ability (BIMS score of 12), also reported being spoken to in a disrespectful manner by S8CNA. Resident #70, who had a BIMS score of 11, expressed distress over S8CNA's stern and condescending communication, particularly during an incident involving the use of a bathroom due to a broken toilet. This resident's upset demeanor was corroborated by staff observations. Resident #82, with a BIMS score of 15 indicating intact cognitive ability, described S8CNA's interactions as rude and unprofessional. She reported an incident where S8CNA refused to apply cream to her skin, which was needed due to irritation from a brief. This behavior was reported to the CNA supervisor, S9CNAS, who confirmed the expectation for all staff to treat residents with respect and dignity. The facility's administration was aware of these issues, as evidenced by the suspension of S8CNA following the reports from Residents #70 and #82.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, both of whom were at risk for falls. Resident #2, who was admitted with diagnoses of cerebral infarction and hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the left non-dominant side, was observed sitting in a Geri chair with the call light tied to the bed rail against the wall, out of her reach. During an interview, Resident #2 confirmed she could not reach her call light. A CNA and an LPN both observed and confirmed that the call light was not within reach, despite the resident being capable of using it. Similarly, Resident #83, who was admitted with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, was observed sitting in a wheelchair with the call light tied to the bed rail, not within his reach. Resident #83 confirmed he could not reach his call light. An LPN observed and confirmed the call light was not within reach. The Director of Nursing was informed of these findings and confirmed that call lights should be within reach when residents are in their rooms.
Failure to Ensure Resident Privacy During ADL Care
Penalty
Summary
The facility failed to provide privacy to a resident during assistance with personal care, specifically when changing a soiled brief and bed linens. The incident involved a resident who was always incontinent of bowel and bladder, sharing a room with another resident. During the observation, the privacy curtain was not pulled between the resident and his roommate, allowing the roommate to visualize the resident's unclothed body. The resident's soiled shirt and bed linens were observed on the floor, and the staff member providing care confirmed the failure to ensure privacy. Interviews with staff members, including the CNA who provided care and another CNA who entered the room, confirmed the observations and acknowledged that the privacy curtain should have been pulled to protect the resident's dignity and privacy. The Assistant Director of Nursing and the Administrator were informed of the findings and also confirmed that the privacy curtain should have been used during the provision of ADL care to prevent the resident from being visualized by his roommate.
Failure to Use Required Lift Equipment Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident who required the assistance of two staff members and a mechanical lift for transfers was free from accident hazards. On the morning of the incident, a CNA attempted to transfer the resident from her bed to a wheelchair alone, without using the required mechanical lift. The CNA was unaware of the resident's need for a total lift transfer, which was clearly documented in the resident's care plan and facility's lifting policy. The resident, who had diagnoses including generalized muscle weakness and congestive heart failure, was assessed as needing two-person assistance for transfers. During the transfer attempt, the resident began to slide out of the wheelchair, and the CNA guided her to the floor. Initially, the resident did not complain of pain, but later in the day, she reported significant pain in her left leg, which was found to be edematous. The resident was subsequently diagnosed with fractures in her left tibia and fibula, as well as a proximal right tibial fracture. Interviews with facility staff revealed that the CNA did not know the resident required a total lift and did not use the appropriate equipment or seek assistance. The CNA admitted to transferring the resident alone and was unaware of the resident's transfer requirements. The incident was witnessed, and the facility's incident report documented the CNA's actions and the resident's subsequent injuries.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that as-needed (PRN) orders for psychotropic medications were limited to 14 days and included a specified duration for a resident. The clinical record review of a resident revealed that upon admission, there was a physician's order for Temazepam 7.5 mg tablet to be administered by mouth as needed for insomnia at night. This order, written on June 3, 2024, did not include a stop date or duration, which is a requirement for PRN psychotropic medications. The Medication Administration Record (MAR) for June 2024 also showed that the PRN medication was administered without a stop date or duration. During an interview, the Director of Nursing (DON) confirmed that Temazepam is a psychotropic medication and acknowledged that it was ordered PRN for longer than 14 days without a specified stop date or duration.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baton Rouge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Oaks Nursing & Rehabilitation Center Llc | 2.6 mi | ★★★★★ | 2 | 0 |
| Central Guest House Healthcare & Rehabilitation Ce | 5.7 mi | ★★★★★ | 6 | 0 |
| The Lodge At Lane | 6.1 mi | ★★★★★ | 0 | 0 |
| Zachary Manor Nursing And Rehabilitation Center | 6.3 mi | ★★★★★ | 9 | 0 |
| St Clare Manor Nursing And Rehabilitation | 7.3 mi | ★★★★★ | 4 | 0 |
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