Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Heritage Manor Of Baton Rouge Ii during CMS and state inspections, most recent first.
Failure to provide timely incontinence care for two residents. One resident with dementia and moderate cognitive impairment, and another resident with dementia who was dependent on staff for toileting, both had care plans calling for q2h checks, toileting assistance, and peri-care after each incontinent episode. Observations showed each resident remained in the dining room for hours without being checked or changed, and both were later found saturated with urine; staff and the DON confirmed the q2h checks and changes had not occurred.
Controlled drug counts were not accurately reconciled for two medication carts. An LPN documented controlled meds as administered or prepared for administration, but the packets and narcotic records did not match for a resident’s alprazolam, another resident’s lorazepam, and a third resident’s tramadol. The LPN confirmed the discrepancies and stated the meds were not signed out at the time of administration, and the DON stated the narcotic record should accurately reflect the quantity available at all times.
A resident with dementia, frequent falls, and severe cognitive impairment was placed in a soft waist self-release belt in her wheelchair after a fall. The belt was observed fastened while she sat at the dining room table, and an LPN confirmed she could not release it on her own. Staff described the belt as a fall-prevention safety device, but no restraint assessment was completed and the DON confirmed the belt would restrict the resident from standing up.
A resident receiving continuous enteral feeding had a tube feeding bag observed without the resident’s name, date, time, or infusion rate documented, despite the facility policy requiring labeling of the container. The resident had a gastrostomy and diagnoses including CVA, hemiplegia, aphasia, and dysphagia; an LPN and the DON both confirmed the bag was unlabeled and should have been labeled.
Three residents receiving pain management medications had administrations recorded on narcotic log sheets but not on their MARs. Interviews with an LPN and the DON confirmed that facility procedures require matching documentation on both records, but this was not done for multiple administrations of Oxycodone/Acetaminophen and Morphine Sulfate for residents with conditions such as osteoarthritis, pressure ulcers, and spinal stenosis.
A facility failed to ensure staff wore proper PPE during care for a resident on Enhanced Barrier Precautions (EBP) due to a sacral pressure ulcer. Despite facility policy requiring gloves and gowns for high-contact activities, a CNA was observed providing perineal care without a gown. The CNA acknowledged the oversight, and the DON confirmed the requirement for gown use in such cases.
A resident with dementia and a protective order was removed from a locked unit by family members without staff supervision. The facility failed to report the incident to law enforcement and the state agency, resulting in Immediate Jeopardy. The administration believed the resident had not eloped since she left with family, despite policy requirements.
A resident with a protective order and an open EPS case was removed unsupervised from a locked unit by family members due to the facility's failure to develop and implement a comprehensive care plan. Staff were not informed of the protective order, leading to the resident's disappearance and subsequent location with a family member two days later.
A resident with a history of wandering and a protective order was allowed to leave a locked unit unsupervised with unknown family members, resulting in the resident being missing for two days. The facility failed to document and communicate the resident's elopement risk and protective order to staff, leading to inadequate supervision and the resident's elopement.
A resident with dementia and an active protective order was removed from a locked unit by unknown family members without staff supervision. The facility failed to communicate the resident's elopement risk and protective order to staff, resulting in the resident being missing for two days. The incident was not reported to authorities, highlighting administrative oversights.
The facility failed to accurately code the MDS assessments for three residents regarding the use of wander/elopement alarms. Despite having wander guards in place, the MDS assessments were incorrectly coded as not using these alarms. Staff interviews confirmed the inaccuracies, and the Director of Nursing acknowledged the expectation for accurate coding.
The facility failed to maintain a sanitary and safe environment, with unsanitary AC units in resident rooms, cracked ceiling tiles, chipped floor tiles, and an unclean bathroom. A resident expressed concern about the impact of these conditions on her health. Staff acknowledged the need for regular cleaning and maintenance, but issues persisted due to lack of materials and oversight.
The facility failed to incorporate PASARR Level II recommendations into the care plans of four residents with serious mental illnesses, resulting in inaccurate MDS coding and lack of necessary services. Despite specific recommendations for counseling, therapy, and crisis intervention, these were not documented or implemented, as confirmed by facility staff.
A resident with PTSD did not receive trauma-informed care due to multiple oversights in documentation and communication among staff. The PTSD diagnosis was not reflected in the MDS or care plan, and staff were unaware of necessary interventions. Social assessments inaccurately recorded no history of trauma, and the psychiatric nurse practitioner did not inquire about PTSD due to the resident's nonverbal status. The lack of awareness and proper documentation led to the deficiency.
A long-term care facility was found to have a medication error rate of 41.03%, exceeding the acceptable limit of 5%. Two residents were affected by these errors: one resident received Furosemide without a required blood pressure check, and another resident's medications were administered outside the prescribed time window. These deficiencies were confirmed through observations and interviews with the involved LPNs and the DON.
The facility failed to store drugs and biologicals according to professional principles, as 22 loose pills were found on Med Cart B. This was confirmed by an LPN and the DON, indicating non-compliance with the facility's medication storage policy.
A facility failed to maintain proper infection control during perineal care for a resident with a history of UTIs. A CNA did not perform hand hygiene after removing soiled gloves and before applying clean ones, and continued to handle the resident's clothing and wheelchair with soiled gloves. Interviews confirmed the failure to follow infection control procedures, which could potentially lead to UTIs.
A resident with cognitive impairment was physically abused by another resident on the smoking patio, resulting in scratches to her arm and face. The incident was confirmed through video footage and staff reports, highlighting a failure to protect the resident from harm despite the facility's policy against abuse.
A resident was transferred to a hospital and not accepted back due to aggressive behaviors and elopement risk, but the facility failed to document the justification for the discharge in the medical record. Interviews with the hospital social worker and facility staff confirmed the absence of necessary documentation, highlighting a deficiency in the facility's discharge process.
A resident was transferred to a hospital due to behaviors that endangered safety, and the facility initiated a discharge the following day. However, the Ombudsman was not provided with the discharge notification until eight days later, despite being verbally informed of the transfer. This lapse in notification compliance could affect any of the 119 residents in the facility.
A facility failed to complete and transmit a reentry MDS assessment for a resident in a timely manner. The resident returned from the hospital, and although the assessment was initiated, it was not completed or transmitted within the required time frames. Staff confirmed the oversight, acknowledging the 7-day completion and 14-day transmission deadlines were missed.
A resident with Dysphagia and Gastrostomy had a physician's order for continuous tube feeding, which was not followed as the feeding pump was found turned off. Staff confirmed the feeding should have been infusing continuously, highlighting a failure to adhere to the care plan and physician's directives.
A staff member failed to follow Enhanced Barrier Precautions by not wearing a gown during incontinent care for a resident with multiple wounds, despite facility policy requiring both gown and gloves for high-contact activities. The oversight was acknowledged by the staff member and confirmed by the Director of Nursing, indicating a lapse in infection control adherence.
The facility did not post daily nurse staffing information as required by its policy, which mandates posting details such as the facility name, current date, total number and actual hours worked by nursing staff, and resident census. Observations revealed missing documentation for specific dates, and the administrator confirmed the oversight, acknowledging the failure to comply with the policy.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received assistance with incontinent care for 2 of 4 residents reviewed for ADLs. The facility policy titled "Toileting Resident" stated that residents are to be toileted safely on a routine basis in a timely manner according to their individual plan of care. Resident #7 had diagnoses including dementia and generalized muscle weakness, a Significant Change MDS showing a BIMS of 12 indicating moderate cognitive impairment, and a care plan directing staff to check her every two hours, assist with toileting as needed, and provide peri-care after each incontinent episode. Her family filed grievances related to her not being changed in a timely manner, and during observation she remained in the dining room without being checked, changed, or toileted for several hours before staff brought her to the bathroom, where her brief was saturated with urine and her pants and wheelchair showed wet residue. Resident #85 had diagnoses including dementia and muscle atrophy and wasting, was unable to complete the BIMS interview, and was dependent on staff for toileting. Her care plan also directed staff to check her every two hours, assist with toileting as needed, and provide peri-care after each incontinent episode. During observation, she remained in the dining room without being checked for incontinence or changed for several hours before staff provided incontinence care, at which time her gray sweat pants were observed to be saturated in the front and back. Staff interviews confirmed that both residents had not been checked or changed every two hours as required, and the DON stated residents should be checked for incontinence and changed every two hours and as needed.
Controlled Drug Counts Were Not Accurately Reconciled
Penalty
Summary
The facility failed to ensure controlled drugs were accurately reconciled for 2 of 2 medication carts observed for controlled drug reconciliation. The facility policy stated controlled medications are to be signed out on the Individual Resident Narcotics Record at the time they are to be administered, and the DON stated the narcotic record should accurately display the quantity of controlled medications available at all times. During observation of Medication Cart A, Resident #46’s Alprazolam 0.5 mg packet contained 55 tablets while the narcotic record showed a remaining balance of 54 tablets after a documented 7:00 a.m. administration. The LPN confirmed the discrepancy and stated she signed out the medication during morning medication pass but forgot to administer it, adding that controlled medications should be prepared and administered at the time they are signed out. During observation of Medication Cart B, Resident #86’s Lorazepam 0.5 mg packet contained 47 tablets while the record showed 48 remaining, and Resident #117’s Tramadol 50 mg packet contained 24 tablets while the record showed 25 remaining. The LPN confirmed both discrepancies and stated she forgot to sign the medications out at the time of administration during morning medication pass.
Unassessed wheelchair seatbelt used as a restraint
Penalty
Summary
The facility failed to ensure a resident was free from the use of a physical restraint unless it was needed for medical treatment. Resident #113 had diagnoses including dementia and frequent falls, and her annual MDS showed severe cognitive impairment with a BIMS score of 4. Her record showed no physician order for restraints and no physical restraint assessment was completed, yet her care plan included a soft waist self-release belt applied while she was in her wheelchair to reduce fall probability. After a fall on 02/02/2026, nursing notes documented that the resident had attempted to ambulate independently and then a new fall intervention was added: a soft waist self-release belt in the wheelchair. During observations on 03/04/2026 and 03/05/2026, the resident was seen sitting in her wheelchair at the dining room table with a soft seatbelt fastened at her waist. An LPN later asked the resident to release the seatbelt four times, and although the resident placed her fingers on the release button, she did not release the belt. Staff interviews showed conflicting understanding of the device. One LPN stated the resident could stand and pivot and that the belt was used for fall prevention, while another LPN said the resident was to wear it at all times while up in her wheelchair and confirmed the resident was unable to release it. The DON stated seatbelts on the unit were considered safety devices and not restraints, and that no restraint assessments were completed for residents with seatbelts initiated. The DON also confirmed the resident’s seatbelt would restrict her from standing up.
Unlabeled Tube Feeding Bag
Penalty
Summary
The facility failed to ensure appropriate care for a resident receiving enteral feeding when the tube feeding bag was observed without the resident’s name, date, time, or rate documented on the bag. The report states that the facility’s policy on tube feeding required labeling of the container, and the resident’s physician orders directed Diabetasource AC at 75 mL/hour continuously. Resident #91 was admitted with diagnoses including cerebral infarction due to thrombosis of the left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction, aphasia following cerebral infarction, dysphagia, oropharyngeal phase, and encounter for attention to gastrostomy. During observation, the resident’s tube feeding was running at 75 mL/hour, but the feeding bag had no identifying label. An LPN stated that a new tube feeding bag should be labeled with the resident’s name, date, time, and rate of infusion, and the DON confirmed the bag was unlabeled and should have been labeled.
Failure to Accurately Document Medication Administration on MARs
Penalty
Summary
The facility failed to maintain accurate medication administration records (MAR) in accordance with professional standards for three residents. For each resident, there were discrepancies between the narcotic log sheets and the MARs. Specifically, medications such as Oxycodone/Acetaminophen and Morphine Sulfate were documented as administered on the narcotic log sheets, but these administrations were not recorded on the corresponding MARs for multiple dates. One resident with primary generalized osteoarthritis and multiple wounds, who was also under hospice care, had several instances where the narcotic log indicated administration of Oxycodone/Acetaminophen, but the MAR did not reflect these administrations. Another resident with a stage 2 pressure ulcer and chronic pain, also on hospice, had Morphine Sulfate administration documented on the narcotic log but not on the MAR. A third resident with spinal stenosis and a stage 2 pressure ulcer, also under hospice care, had multiple doses of Oxycodone/Acetaminophen recorded on the narcotic log but not on the MAR. Interviews with nursing staff, including an LPN and the DON, confirmed that facility procedures require nurses to document medication administration on both the narcotic log and the MAR. Both staff members acknowledged that the narcotic log and MAR should match, and confirmed that in these cases, the MARs did not accurately reflect the administrations recorded on the narcotic logs.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to proper infection prevention and control protocols, specifically regarding the use of Personal Protective Equipment (PPE) during care activities for a resident on Enhanced Barrier Precautions (EBP). The facility's policy, revised in March 2024, mandates the use of gloves and gowns for high-contact activities such as changing briefs or assisting with toileting for residents with conditions like pressure ulcers. Resident #3, who was admitted with a diagnosis of a sacral pressure ulcer, was on EBP as per physician orders starting August 1, 2024. On March 19, 2025, an observation was made of a Certified Nursing Assistant (CNA) providing perineal care to Resident #3 without wearing a gown, despite the EBP sign on the resident's door indicating the requirement for both gloves and a gown. The CNA acknowledged the oversight and confirmed the resident's EBP status due to a wound. The Director of Nursing (DON) was informed of the incident and confirmed that staff should wear a gown when providing care to residents on EBP.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an incident of neglect involving a resident's elopement in a timely manner to the State Survey Agency and local law enforcement. The incident involved a resident with a history of dementia, encephalopathy, altered mental status, and housing instability, who was residing in a locked unit due to wandering behaviors. Despite having an active protective order against family members, the resident was removed from the facility by two unknown family members without staff supervision or knowledge. On the evening of the incident, a CNA allowed the resident's daughter and granddaughter to take the resident outside for a visit. When the CNA checked on the resident, it was discovered that the resident was no longer on the premises, and her belongings were missing. The facility's staff, including the LPN and DON, were informed of the resident's disappearance, but law enforcement and the state agency were not notified immediately as required by state law. The facility's administration, including the Administrator and Regional Vice President, decided not to report the incident to law enforcement or the state agency, believing that the resident had not eloped since she left with family members. This decision was made despite the facility's policy requiring the reporting of such incidents. The failure to report the incident resulted in an Immediate Jeopardy situation, as the resident was located two days later with a family member, highlighting the potential for more than minimal harm to all residents in the facility.
Removal Plan
- All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. Identified as two residents with secure care bracelets and 32 residents on the secure care unit.
- All resident electronic charts and hard copy charts were audited by the DON and ADON to ensure that no other residents had an order for protection. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned.
- All resident electronic charts and hard copy charts for residents considered an elopement risk were audited by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan.
- Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.
- Regional [NAME] President will review all SIMs reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.
- An immediate in-service was initiated by the Director of Nurses with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was completed with present staff and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member.
- To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress.
- The NFA or designee will interview 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.
- An Emergency QA was held with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.
- Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.
- Completion date - The likelihood for serious harm will no longer exist.
Failure to Implement Comprehensive Care Plan Leads to Resident's Unsupervised Removal
Penalty
Summary
The facility failed to develop and implement a Comprehensive Person-Centered Care Plan for a resident, which resulted in an Immediate Jeopardy situation. The resident, who resided on a locked unit due to wandering behaviors, was admitted with a known protective order and an open Elderly Protective Service (EPS) case against family members. Despite these critical details, the facility did not ensure that staff were aware of the protective order or the EPS case, leading to the resident being removed from the facility by family members without supervision. The deficiency was highlighted when staff allowed two unknown family members to take the resident outside unsupervised. The staff, including a CNA and an LPN, were not informed about the protective order and EPS case, which would have prompted them to be more cautious. The resident was later found with a family member two days after being removed from the facility, indicating a significant lapse in communication and care planning. Interviews with various staff members, including the Care Manager, Social Worker, and Director of Nursing, revealed that the facility did not have a process in place to communicate critical information about protective orders and EPS cases to direct care staff. This lack of communication and failure to incorporate these details into the resident's care plan directly contributed to the resident's unsupervised removal from the facility, posing a risk to the resident's safety.
Removal Plan
- Corrective actions for the alleged deficient practice of the facility failing to ensure a comprehensive person-centered care plan to ensure nursing staff were aware of Resident #3's needs and make staff aware of Resident #3's current protective orders against 3 family members.
- All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit).
- All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned.
- All resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan.
- Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.
- Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.
- An immediate in-service was initiated by the Director of Nurses with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurses' station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member.
- To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission. The DON, will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress.
- The NFA or designee will interview 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.
- An Emergency QA was held with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.
- Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.
Resident Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident from the locked unit. The resident, who had a history of wandering behaviors and was admitted with a protective order and an open Elderly Protective Services (EPS) case against family members, was allowed to leave the facility unsupervised with two unknown family members. This incident occurred despite the resident being identified as an elopement risk due to their medical conditions, including dementia and encephalopathy. The resident's clinical records indicated a risk for elopement, but the necessary precautions were not documented or communicated effectively to the staff. The resident was not included in the facility's wander guard list or the elopement risk list, and the staff was not informed of the protective order or the EPS case. This lack of communication and documentation led to the resident being removed from the facility without supervision, resulting in the resident being missing for two days before being located with a family member. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk and the protective order. The CNA responsible for the resident on the day of the incident was unaware of these risks and allowed the resident to leave with family members unsupervised. The LPN and other staff members also confirmed they were not informed of the resident's status, which contributed to the failure to prevent the elopement.
Removal Plan
- Facility NFA contacted Elderly Protective Services to alert them resident #3 left the facility. NFA alerted the facility Ombudsman that the resident's family removed her from the facility.
- All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. Identified as two residents with secure care bracelets and 32 residents on the secure care unit.
- All resident electronic charts and hard copy charts were audited by the DON and ADON to ensure that no other residents had an order for protection. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned.
- All resident electronic charts and hard copy charts for residents considered an elopement risk were audited by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan.
- Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.
- Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.
- An immediate in-service was initiated by the Director of Nurses with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was completed with present staff and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member.
- To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission. The DON will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly to promote compliance and gauge progress.
- The NFA or designee will interview 5 staff members 3 x a week to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.
- An Emergency QA was held with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.
- Should the above referenced measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.
Failure to Communicate Protective Order and Elopement Risk Leads to Resident's Unauthorized Removal
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency that compromised the safety and well-being of a resident. The deficiency involved the failure to communicate critical information about a resident's protective order and elopement risk to direct care staff. This oversight led to an incident where the resident, who was on a locked unit due to wandering behaviors, was removed from the facility by unknown family members without staff supervision or knowledge. The resident was missing for two days before being located with a family member. The resident in question had a history of dementia, encephalopathy, and altered mental status, and was admitted to the facility with an active protective order against family members due to domestic abuse concerns. Despite these significant risk factors, the facility did not develop a comprehensive care plan or implement interventions to ensure staff were aware of the protective order or the open Elderly Protective Services (EPS) case. The Director of Nursing (DON) and other administrative staff failed to update the elopement risk list and did not communicate the resident's status to direct care staff, contributing to the resident's unauthorized removal from the facility. Additionally, the facility did not report the elopement incident to the state agency or local law enforcement as required by state law. The DON and Administrator were aware of the resident's disappearance but chose not to notify authorities, believing the resident had not eloped since she left with family members. This decision was made despite the inability to identify the family members involved and the existing protective order. The lack of timely reporting and communication further exacerbated the situation, highlighting significant administrative oversights in handling the resident's care and safety.
Removal Plan
- Facility NFA contacted Elderly Protective Services to alert them Resident #3 left the facility.
- NFA alerted the facility Ombudsman that the resident's family removed her from the facility.
- All resident electronic charts and hard copy charts were audited by the DON and ADON to ensure that no other residents had an order for protection.
- All resident electronic charts and hard copy charts for residents considered an elopement risk were audited by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately.
- Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689.
- Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.
- Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely.
- Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.
- Regional [NAME] President will oversee in-servicing/monitoring of the NFA and administrative staff to ensure all audits are completed appropriately and timely.
- An immediate in-service was initiated by the Director of Nurses with staff present at the facility at the time.
- All staff that were not present will be in-serviced prior to their next shift.
- The staff were in-serviced regarding: Residents with EPS cases.
- All residents with EPS cases will have a care plan and the information communicated to the staff immediately.
- All visits will be supervised.
- Should anyone try to leave with the resident the police will be called and it will be reported to the state.
- The Administrator and DON will be notified.
- Any resident classified as an elopement risk will be placed in the binder at the nurse's station.
- In the instance of elopement, the police will be called and a report shall be made to the state.
- The in-servicing was completed with present staff and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee.
- A master list of all staff was generated by the Human Resources Director.
- The DON and ADON used this list to retrain every staff member.
- The ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON.
- This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop.
- These audits will continue for every new admission for the next 30 days.
- The DON will audit 5 residents who are an elopement risk 3 times a week for four weeks and routinely thereafter.
- The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/communicated to staff.
- Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team.
- The Quality Assurance (QA) Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress.
- The NFA or designee will interview 5 staff members 3 times a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.
- An Emergency QA was held with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.
- Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time.
- Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.
Inaccurate MDS Coding for Wander/Elopement Alarms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents regarding the use of wander/elopement alarms. Resident #3, who was admitted with a diagnosis of Dementia, had a wander guard task initiated on February 4, 2025, but the Admission MDS with an Assessment Reference Date (ARD) of February 6, 2025, was incorrectly coded as not using a wander/elopement alarm. Similarly, Resident #R2, with diagnoses including Alzheimer's disease and Dementia, had a wander guard task initiated on July 31, 2024, but the Quarterly MDS with an ARD of January 19, 2025, was also incorrectly coded as not using the alarm. Resident #R3, diagnosed with Dementia, had a similar issue with the Quarterly MDS dated December 18, 2024, being inaccurately coded. Interviews with staff members confirmed the inaccuracies in the MDS coding. S4CM, responsible for MDS, acknowledged the error in Resident #3's Admission MDS, confirming that it should have been coded as using a wander/elopement alarm. Similarly, S5MDS confirmed the inaccuracies in the MDS assessments for Residents #R2 and #R3, stating that both should have been coded as using the alarms. The Director of Nursing (S3DON) also reviewed the findings and confirmed the inaccuracies, expecting staff to code MDS assessments accurately.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. Observations revealed unsanitary conditions in resident rooms and common areas. In Room B, the air conditioning unit vent was covered with a copious amount of black specks, and in Room E, the AC unit had dry brown and red liquid stains. Ceiling tiles in Hall A and Room B were not maintained, with cracks and brown water spots observed. Room C had chipped floor tiles, creating a potential hazard. Bath D was found in an unsanitary state, with light fixtures and ceiling vents covered in a gray fluffy substance, and the laminate flooring had spaces filled with black residue and was sticky. Interviews with staff and residents confirmed these observations. A resident in Room B expressed concern that the black substance on the AC unit could worsen her breathing issues. Staff members acknowledged the need for regular cleaning and maintenance, admitting that the AC units should be wiped daily and bathrooms cleaned at least once daily. The maintenance staff was aware of the cracked ceiling tiles and chipped floor tiles but lacked the materials to make repairs. The administrator confirmed the need for cleanliness and maintenance, acknowledging the unacceptable state of the AC units and the need for repairs in Bath D.
Failure to Implement PASARR Level II Recommendations
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) Level II determinations and recommendations for four residents. These residents were identified as having serious mental illnesses or related conditions, requiring specific services and interventions as outlined in their PASARR Level II Evaluation Summaries. However, the facility did not incorporate these recommendations into the residents' care plans, nor did they accurately code the PASARR Level II status in the Minimum Data Set (MDS) assessments. Resident #2, diagnosed with Paranoid Schizophrenia, Major Depressive Disorder, Schizoaffective Disorder, and Anxiety Disorder, was approved for admission with specific recommendations for counseling, crisis intervention, and therapy. Despite these recommendations, the resident's care plan lacked documentation of the PASARR Level II and the necessary services were not implemented. Similarly, Resident #10, with diagnoses including Dementia and Schizoaffective Disorder, was not provided with the recommended training and therapy services, and their PASARR Level II status was inaccurately coded. Residents #27 and #100 also experienced similar deficiencies. Resident #27, with Paranoid Schizophrenia and Dementia, was not provided with the recommended crisis intervention and therapy services. Resident #100, diagnosed with PTSD, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder, did not receive the recommended services for independent living skills and structured leisure activities. In all cases, the facility staff confirmed the inaccuracies in the MDS coding and the absence of PASARR Level II documentation in the care plans.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's clinical record indicated an admission with a PTSD diagnosis, yet the Admission Minimum Data Set (MDS) did not reflect this diagnosis, and the care plan lacked any mention of PTSD. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing, revealed a lack of awareness regarding the resident's PTSD diagnosis and the necessary interventions to prevent triggers or trauma reoccurrence. The psychiatric notes and physician's progress notes confirmed the PTSD diagnosis, but the social history and assessments inaccurately recorded that the resident had not experienced traumatic events or symptoms. The psychiatric nurse practitioner admitted to not inquiring about the resident's PTSD due to her nonverbal status and did not contact the responsible party for further information. The social worker and her assistant, responsible for completing social assessments, failed to identify the PTSD diagnosis, leading to a lack of appropriate referrals and interventions. The MDS coordinator acknowledged that the PTSD diagnosis was not coded in the MDS, which would have prompted the creation of a care plan. The administrator confirmed the oversight in assessing the resident for PTSD and the absence of a care plan addressing the diagnosis and potential triggers. This series of oversights and miscommunications among the staff resulted in the resident not receiving the trauma-informed care required by professional standards.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 41.03% error rate observed during medication administration for two residents. A total of 39 medication administration opportunities were observed, resulting in 16 errors. This deficiency was identified during observations, interviews, and record reviews conducted by surveyors. For Resident #23, the facility did not adhere to the physician's order to check blood pressure before administering Furosemide 20 MG. The resident's clinical record indicated a diagnosis of Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Edema Unspecified. The physician's order specified that Furosemide should be held if the systolic blood pressure was less than 100. However, the LPN administering the medication failed to obtain the resident's blood pressure prior to administration, which was confirmed during an interview with the LPN and the Director of Nursing (DON). Resident #31 experienced a medication timing error. The resident's clinical record included diagnoses such as Chronic Diastolic Heart Failure and Vascular Dementia, among others. The MAR indicated that several medications were scheduled for administration at 8:00 a.m., but they were administered after 9:00 a.m., outside the acceptable window of one hour before or after the scheduled time. This was confirmed by the LPN responsible for the administration and the DON, who acknowledged that the medications were given outside the prescribed timeframe, constituting a medication error.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles. During an observation of Med Cart B, 22 loose medication pills were found, which is against the facility's policy that requires medication carts to be maintained in a clean and orderly manner. This observation was confirmed by S6LPN, who acknowledged that there should be no loose medication pills on the cart. Additionally, S2DON confirmed the same during an interview, indicating a lapse in adherence to the facility's medication storage policy.
Inadequate Infection Control During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically during the provision of perineal care for a resident with a history of urinary tract infections (UTIs). The facility's policy on perineal care, revised in January 2024, outlines the necessity of performing hand hygiene and proper glove use to prevent infections. However, during an observation, a CNA was seen assisting a resident with perineal care without adhering to these guidelines. The CNA did not perform hand hygiene after removing soiled gloves and before applying clean ones, and continued to handle the resident's clothing and wheelchair with soiled gloves. Interviews with the CNA, another CNA, and the Director of Nursing (DON) confirmed the observations and acknowledged the failure to follow proper infection control procedures. The resident involved had a documented history of UTIs, with recent infections noted in September, November, and late November 2024. The DON confirmed that the improper glove use and lack of hand hygiene could potentially lead to UTIs, highlighting the importance of adhering to the facility's infection control policies.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident #1, who was cognitively impaired with a BIMS score of 9, was found with scratches on her arm and face after an altercation on the smoking patio. The incident was reported as physical abuse, with Resident #2, who was cognitively intact with a BIMS score of 15, identified as the aggressor. Resident #2's clinical record indicated a history of physical behavioral symptoms directed towards others. On the day of the incident, staff members observed Resident #1 with injuries and reported the situation to the Director of Nursing. The facility's administration reviewed video footage confirming that Resident #2 had hit Resident #1. The incident was documented in the facility's state agency reportable incidents, and interviews with staff and residents corroborated the occurrence of the altercation. The facility's policy strictly prohibits conduct resulting in resident abuse, yet the incident occurred, indicating a failure to protect Resident #1 from physical harm by another resident.
Failure to Document Justification for Resident Discharge
Penalty
Summary
The facility failed to ensure that a resident's medical record contained the required documentation for an emergency transfer and discharge. Specifically, the clinical record of a resident who was admitted and later transferred to a local hospital did not include documentation justifying the reason for the discharge. The facility's Emergency Transfer Log indicated that the resident was transferred to the hospital and was not accepted back due to aggressive behaviors and elopement risk. However, there was no documentation in the resident's physician or nursing notes to support this decision. Interviews conducted with the social worker at the hospital and the facility's Director of Nursing (DON) confirmed the lack of documentation. The DON acknowledged that the resident exhibited aggressive behaviors and was an elopement risk, which were the reasons for not accepting the resident back. The Administrator also confirmed the absence of documentation justifying the discharge, despite acknowledging the resident's aggressive behavior upon admission. This lack of documentation constitutes a deficiency in the facility's handling of the resident's transfer and discharge process.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding the discharge of a resident who was transferred to a local hospital. The resident was admitted to the facility and later transferred due to an emergency situation involving behaviors that endangered the safety of individuals in the facility. The facility initiated the discharge on the day following the transfer, but the Ombudsman was not provided with a copy of the discharge notification until eight days later, despite being verbally informed of the transfer. Interviews with facility staff confirmed that the discharge was initiated by the facility and that there was no documentation proving that the Ombudsman was notified immediately as required. The Ombudsman only received the discharge letter after requesting it, indicating a lapse in the facility's compliance with notification requirements. This deficiency had the potential to affect any of the 119 residents residing in the facility.
Failure to Timely Complete and Transmit Reentry MDS Assessment
Penalty
Summary
The facility failed to ensure a reentry MDS assessment was completed and transmitted timely for one of the residents reviewed for Resident Assessment. The resident was admitted to the facility and later sent to the hospital. Upon returning to the facility, a reentry MDS assessment was opened but remained incomplete and was never transmitted. Interviews with staff confirmed that the assessment was performed but not completed or transmitted within the required time frames. The staff acknowledged that they had 7 days to complete the assessment and 14 days from the reentry date to transmit it, but these deadlines were not met.
Failure to Implement Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to ensure that physician's orders for tube feedings were implemented for a resident with specific medical conditions. The resident, who was admitted with diagnoses including Dysphagia Oropharyngeal Phase and Gastrostomy, had a physician's order for a continuous tube feeding of Peptamen at 65 ml/hour to deliver necessary calories and protein. However, during an observation, it was found that the tube feeding pump was turned off, despite the bag containing 700 ml of formula labeled for that day. Interviews with staff confirmed the deficiency. A staff member acknowledged that the tube feeding should have been infusing continuously as per the physician's orders. The Director of Nursing also confirmed that nurses are required to follow all physician orders regarding tube feedings and that there were no orders to hold the feeding for this resident. This oversight indicates a failure to adhere to the established care plan and physician's directives for the resident's nutritional needs.
Inadequate Use of PPE During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) during resident care. Specifically, a staff member, identified as S4S, did not adhere to the Enhanced Barrier Precautions (EBP) policy while performing incontinent care for a resident with multiple wounds, including gangrene and pressure ulcers. The facility's policy required the use of both gown and gloves for high-contact activities, but S4S only wore gloves during the care of the resident, who was on EBP due to her condition. The deficiency was observed during a survey when signage on the resident's door indicated the need for EBP, yet the staff member failed to comply with the gown requirement. During an interview, S4S acknowledged the oversight and confirmed the resident's EBP status due to her wounds. The Director of Nursing (S2DON) also confirmed the expectation for staff to wear gowns when in direct contact with residents on EBP, highlighting a lapse in adherence to the facility's infection control protocols.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a prominent location accessible to residents and visitors, as required by their policy. The policy, dated June 2024, mandates that the facility must post specific information daily, including the facility name, current date, total number and actual hours worked by nursing staff, and the resident census. An observation on August 1, 2024, at 9:45 a.m. revealed that the staffing data sheet dated July 30, 2024, lacked documentation of the actual hours worked by registered nurses, licensed practical nurses, or certified nurse aides. Additionally, there was no documentation of staffing data sheets for July 31, 2024, or August 1, 2024. During an interview on August 1, 2024, at 9:46 a.m., the administrator (S1ADM) confirmed that the staffing data sheets should include the actual hours worked by nursing staff and should be completed and posted daily. The absence of this information was acknowledged as a failure to comply with the facility's policy, potentially affecting any of the 122 residents residing in the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 130 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Landmark Of Baton Rouge | 0 mi | ★★★★★ | 8 | 0 |
| Jefferson Manor Nursing And Rehab Ctr, Llc | 0.7 mi | ★★★★★ | 5 | 0 |
| Ollie Steele Burden Manor | 1.5 mi | ★★★★★ | 10 | 0 |
| White Oak Post Acute Care | 1.6 mi | — | 12 | 1 |
| Center Point Health Care And Rehab | 1.8 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.