Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Landmark Of Baton Rouge during CMS and state inspections, most recent first.
Loose and unlabeled pills were found in 2 medication carts during observation. An LPN confirmed the pills should not have been in the drawers, and the DON stated staff were expected to check each shift for loose medications in the carts.
Food service safety standards were not followed for residents served meal trays from the kitchen. Required food temperature logs were missing for multiple meal periods, and staff confirmed the documentation should have been completed. In addition, dark red meat drippings were observed on the floor of the main refrigerator during kitchen tours, and both the DPM and DM confirmed the drippings should not have been there.
Room and Bathroom Not Kept Clean and Sanitary: A resident with CVA-related hemiplegia, dysphagia, cognitive communication deficit, and aphasia was observed in a room and bathroom with wet floors and multiple dried brown and white substances on the floor, commode area, paper towel dispenser, wall, and light switch plate. Staff confirmed the room and bathroom had been cleaned that morning, yet the unsanitary conditions were still present and were confirmed by additional staff.
A resident with pneumonia, atrial fibrillation, and moderate cognitive impairment had unlabeled nebulizer tubing and portable oxygen tubing in his room. An LPN and the DON confirmed the tubing should have been labeled with the date it was changed, consistent with facility policy for oxygen equipment.
Medication at Bedside Without Physician Order: A cognitively intact resident with DM2 and dermatitis had a bottle of generic Benadryl on her bedside table on multiple observations, even though there was no physician order allowing self-administration. An LPN and the DON confirmed residents need a physician order to keep medications at the bedside and that the resident should not have had medication in her room.
A resident receiving IV Daptomycin for sepsis due to MRSA missed doses because an LPN documented the medication as not available on two mornings and did not notify other staff. The MAR and progress notes showed the antibiotic was given once, then not administered on two scheduled days, even though the medication was later found in the refrigerator with doses remaining and the DON confirmed weekend pharmacy support was available.
Failure to follow EBP during feeding tube care. A resident with gastrostomy status had an order for gown and glove use during high-contact care, including feeding tube care, and an EBP sign was posted outside the room. An LPN was observed administering a bolus tube feeding without a gown, and the LPN stated she did not think a gown was required. The DON confirmed nurses were expected to wear a gown and gloves for tube feeding.
Nursing staff failed to accurately document and report a witnessed fall involving a resident with severe cognitive impairment and total dependence for ADLs. The LPN and CNAs involved did not record the incident in the medical record or complete an incident report, contrary to facility policy, and administration only became aware after the resident's representative noticed injuries.
The facility failed to ensure accurate MDS assessments for three residents, leading to deficiencies in coding. A resident was not correctly coded for a serious mental illness, another had incomplete documentation for a stage 4 pressure ulcer, and a third was inaccurately coded for discharge status. These errors were confirmed by the MDS coordinators and the DON.
A facility failed to ensure an accurate PASRR for a resident with Bipolar Disorder. The resident's Level I PASRR was incorrectly completed, not reflecting the diagnosis of a serious mental illness. Despite the resident's preadmission records and care plan confirming the diagnosis, the facility did not submit the necessary documentation for a Level II evaluation, even after a request from the Office of Behavioral Health.
The facility failed to maintain proper infection control during catheter care for two residents. A CNA did not change gloves between tasks for one resident, and another resident's catheter bag was repeatedly found on the floor. Both issues were confirmed by staff, highlighting a breach in infection control protocols.
The facility failed to promote and facilitate resident self-determination for two residents. One resident was given bed baths instead of showers as per her family's wishes due to staffing issues. Another resident, who required a Hoyer Lift, was unable to choose when to get back in bed and was only given bed baths instead of being taken to the shower room as per her care plan.
The facility failed to ensure that two residents received scheduled baths and timely incontinence care. One resident did not receive baths on multiple scheduled days, and another resident waited two hours for incontinence care after initiating a call light. Staff interviews and clinical records confirmed these deficiencies.
The facility failed to provide sufficient CNA staff, resulting in inadequate care for residents. Multiple residents missed baths, experienced delays in incontinence care, and did not receive timely assistance with daily living activities due to the high workload and insufficient staffing. Interviews with staff and the DON confirmed the ongoing staffing issues.
A facility failed to provide adequate supervision during a Hoyer Lift transfer for a resident with Hemiplegia and Hemiparesis. Despite the resident's lifting plan requiring two staff members, a CNA independently performed the transfer, contrary to the facility's policy.
Loose and Unlabeled Medications Found in Medication Carts
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with currently accepted professional principles for 2 of 3 medication carts reviewed. Facility policy titled Medication Storage, revised 11/2017, stated medication storage shall meet all applicable federal, state, and local guidelines. During observation of Cart B with an LPN, fifteen loose and unlabeled pills were found on the bottom of the cart drawers, and the LPN confirmed the pills were loose and unlabeled and should not have been there. During observation of Cart A with another LPN, one loose and unlabeled pill was found on the bottom of the cart drawer, and that LPN also confirmed the pill was loose and unlabeled and should not have been there. The DON stated nursing staff were expected to perform medication cart checks on each shift, including checking for loose medications in the cart drawers, and confirmed medications should not be loose and unlabeled in the cart.
Food Temperature Logs Missing and Refrigerator Contaminated
Penalty
Summary
Dietary services were not provided in accordance with professional standards for food service safety for the 117 residents served a meal tray from the kitchen. The facility’s policy required safe and sanitary food preparation and serving conditions, and its monitoring policy required temperatures of potentially hazardous cooked foods to be taken and recorded, with logs maintained for at least three months. However, review of the food temperature log binder on 02/23/2026 showed missing logs for lunch on 02/18/2026, breakfast and lunch on 02/19/2026, dinner on 02/21/2026, and dinner on 02/22/2026. S3DPM and S4DM both confirmed the missing logs should have been documented. The facility also failed to keep the main refrigerator clean and sanitary. During a kitchen tour on 02/23/2026, dark red meat drippings were observed on the floor of the main refrigerator. The Weekly Cleaning Schedule stated refrigerators should be cleaned by dishwashers as needed, and S3DPM confirmed the meat drippings should not have been on the refrigerator floor. When the refrigerator was toured again later that day, the dark red meat drippings were still present, and S4DM again confirmed they should not have been there.
Room and Bathroom Not Maintained in a Sanitary Condition
Penalty
Summary
The facility failed to ensure Resident #15's room and bathroom were clean and maintained in a sanitary manner. Resident #15 was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left dominant side, dysphagia, cognitive communication deficit, and aphasia. During an observation of the bathroom, surveyors noted one foot in front of the commode a clear wet liquid with a dried brown substance approximately 4 cm in length, a large dried brown substance adjacent to the commode base measuring approximately one foot in length and 6 inches in width, a paper towel dispenser covered with a dry white substance, two dry brown markings on the wall next to the trim exiting the bathroom, and four markings of a dried brown substance on the light switch plate. A later observation of the room again found wet floors, and Resident #15 indicated housekeeping had recently cleaned the room. The same bathroom conditions were observed again, including the wet liquid and dried brown substance near the commode, the large dried brown substance adjacent to the commode base, the paper towel dispenser covered with a dry white substance, the brown markings on the wall, and the dried brown substance on the light switch plate. A staff member confirmed she had cleaned and sanitized the room and bathroom that morning, and two additional staff members confirmed the room and bathroom were not clean and sanitary.
Unlabeled Oxygen and Nebulizer Tubing
Penalty
Summary
The facility failed to provide necessary respiratory care by not ensuring oxygen tubing was labeled for Resident #14. The resident was admitted with diagnoses including pneumonia and atrial fibrillation, and his admission MDS showed a BIMS of 11, indicating moderate cognitive impairment. During observation of the resident's room, the tubing connected to his nebulizer and the tubing connected to his portable oxygen canister were not labeled. Facility policy titled Infection Control Oxygen Equipment Cleaning stated that disposable tubing, masks, and cannulas should be used for patients receiving oxygen therapy, tubing should be replaced every 7 days, and when not in use the mask or cannula should be stored in a plastic bag clearly labeled with the resident's name and date. An LPN observed and confirmed that the nebulizer and oxygen tubing were not labeled and should have been, and the DON also confirmed that all nebulizer and oxygen tubing should be labeled with the date it was changed.
Medication at Bedside Without Physician Order
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for a resident. The facility's policy on self-administration of medication stated a resident may self-administer only if the attending physician writes or gives a verbal order allowing the resident to keep medication at the bedside for self-administration, and medications are to be kept in a locked cabinet or box in the resident's room. Resident #51 was admitted with diagnoses including Diabetes Mellitus Type 2 and Dermatitis, and her annual MDS showed a BIMS of 15, indicating she was cognitively intact. Review of her current physician's orders showed no written order for self-administration of medication. Despite this, observations on multiple occasions showed a bottle of generic Benadryl on her bedside table. Nursing staff stated residents should not have medications, including over-the-counter medications, at the bedside without a physician's order to self-administer, and the DON confirmed the resident did not have a self-administration order and should not have had medications in her room.
Missed IV antibiotic doses due to medication not being located
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when ordered IV Daptomycin for sepsis due to MRSA. The resident was admitted with a diagnosis of sepsis due to Methicillin Resistant Staphylococcus Aureus, and hospital discharge orders directed Daptomycin-Sodium Chloride IV solution 1000 mg in the morning for 19 days. The facility’s physician orders and MAR showed the antibiotic was started on 02/20/2026, with documentation that it was administered that day, but it was then charted as a 9, meaning other/see progress notes, on 02/21/2026 and 02/22/2026. Progress notes documented that on 02/21/2026 and 02/22/2026 the medication was not available. The resident stated he did not receive the antibiotic over the weekend and was told the nurse could not find it. An LPN stated she could not find the Daptomycin on those two days and did not notify other staff. Another LPN confirmed the antibiotic should have been given if available and later observed the medication still in the refrigerator in Medication Room A, with three doses remaining. The DON confirmed the facility had weekend pharmacy services and an on-call pharmacy service, and stated the nurse should have notified other staff when the antibiotic could not be found.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
Provide and implement an infection prevention and control program. The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infections for 1 of 2 residents reviewed for feeding tube care. Resident #15 was admitted with a diagnosis including gastrostomy status and had a physician order for Enhanced Barrier Precautions requiring gown and gloves during high-contact resident care activities, including feeding tube care. During an observation, S5LPN administered a bolus tube feeding to Resident #15 without wearing a gown, despite the posted EBP sign outside the resident's door stating that staff must wear gloves and a gown for device care or use, including feeding tube care. When interviewed, S5LPN stated she did not have to wear a gown while administering the tube feeding, while S2DON later confirmed that nurses were expected to follow EBP and wear a gown and gloves when administering tube feeding.
Failure to Document and Report Witnessed Fall
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one resident who experienced a witnessed fall. Specifically, nursing staff did not document the witnessed fall in the resident's medical record or complete an incident report as required by facility policy. The LPN responsible for the resident's care on the morning of the incident confirmed that, after being called for assistance, she and two CNAs manually lifted the resident from the floor back to bed but did not report or document the event, believing it was not a fall. As a result, there was no record of the incident in the nurses' notes, and administration was not notified at the time. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had a care plan indicating a high risk for falls and the need for total lift assistance. The incident only came to light after the resident's representative noticed bruising and discoloration, prompting further investigation. The DON later confirmed that the event should have been documented as a fall and that the required documentation and reporting were not completed by the staff involved.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for three residents, leading to deficiencies in coding. Resident #5 was not correctly coded for having a serious mental illness, despite documentation from a PASRR Level II evaluation indicating such a condition. The MDS coordinator, S3MDS, and the Director of Nursing, S2DON, confirmed the error upon review. This oversight indicates a lapse in accurately reflecting the resident's mental health status in the MDS assessment. Resident #60's MDS assessment was incomplete regarding pressure ulcers, as sections related to unhealed pressure ulcers were left blank. Despite physician orders and wound care documentation indicating a stage 4 pressure ulcer, the MDS did not reflect this condition. Both the wound care nurse, S8WCN, and the MDS coordinator, S5MDS, acknowledged the discrepancy. Additionally, Resident #122 was inaccurately coded for discharge status, with the MDS indicating a discharge to a hospital rather than the resident's home. This error was confirmed by S4MDS and S2DON, highlighting a failure to accurately document the resident's discharge location.
Inaccurate PASRR for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure an accurate Pre-admission Screening and Resident Review (PASRR) for a resident with a mental disorder. The resident, who was admitted with a diagnosis of Bipolar Disorder, had an inaccurately completed Level I PASRR that did not reflect this diagnosis. The admission Minimum Data Set (MDS) indicated that the resident was not considered for a Level II PASRR despite having a serious mental illness. The resident's preadmission records and care plan both confirmed the diagnosis of Bipolar Disorder, yet the Level I PASRR completed by a social worker at a local hospital incorrectly stated that the resident did not have a mental disorder that could lead to chronic disability. Interviews conducted during the investigation revealed that the facility was aware of the inaccurate coding on the Level I PASRR. The Office of Behavioral Health had requested additional documentation to correct the error, but the facility had not responded. The staff member responsible for submitting resident review forms for Level II evaluation confirmed that a resident review form had not been submitted as required. The facility administrator also acknowledged the error and the need for resubmission of the resident review form for a Level II evaluation, which had not been done.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and infection control techniques during catheter care for two residents. For Resident #55, a CNA was observed performing catheter care without changing gloves between tasks, including wiping stool from the resident's buttocks, emptying the catheter bag, and touching the bathroom door handle. This lack of glove change was confirmed by both the CNA and the Director of Nursing (DON), indicating a breach in infection control protocols. Additionally, Resident #60's catheter bag was repeatedly observed lying on the floor over several days, which was confirmed by both a wound care nurse and a CNA. The DON also acknowledged that catheter bags should not be placed on the floor, highlighting a failure to maintain a sanitary environment for residents with catheters. Both residents had a history of urinary tract infections, underscoring the importance of proper infection control measures to prevent further complications.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for two residents. Resident #2, who had diagnoses including Cerebral Infarction and Unspecified Dementia, was supposed to receive showers on specific days as per her family's wishes. However, due to staffing issues, she was given bed baths instead. The CNA assigned to her hall confirmed that she was unable to bring residents to the shower room when working alone, which led to the resident not receiving the type of bath she preferred. Resident #R4, who had diagnoses including Bilateral Primary Osteoarthritis of the Knee and Morbid Obesity, required a Hoyer Lift for transfers and had a care plan that included going to the shower room on Wednesdays. However, due to staffing shortages, she was only given bed baths. Additionally, she was unable to choose when to get back in bed because the CNA informed her that she would have to wait for the next shift. Both CNAs and the Director of Nursing confirmed that residents should be able to choose the type of bath they receive and when to get out of bed, but these choices were not facilitated due to staffing issues.
Failure to Provide Scheduled Baths and Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene. Resident #R4 did not receive scheduled baths on multiple occasions, as confirmed by interviews with the resident and staff. Resident #R4's bath days were Monday, Wednesday, and Friday, but there was no documentation of a bath being given from 03/21/2024 to 03/25/2024. Staff members were unsure of their responsibilities, leading to missed baths. Similarly, Resident #R5, who had severe cognitive impairment, did not receive a bath on his scheduled bath day, 03/23/2024, as confirmed by staff interviews and the resident's own account of not having had a bath in five days. The facility failed to provide documentation for Resident #R5's bath on the scheduled day, indicating a lapse in care and hygiene maintenance for both residents. Additionally, the facility failed to provide timely incontinence care for Resident #R4. On 03/22/2024, Resident #R4's call light was on for two hours before she received assistance with incontinence care after having a bowel movement. During this time, she made multiple calls to the facility from her cell phone, which were confirmed by her call log and the ward clerk. Staff interviews revealed that the CNA assigned to Resident #R4 was occupied with other duties and was unaware of the extended wait time. The LPN on duty also confirmed that a two-hour wait time for a call light was excessive and not in line with the facility's standard of a twenty-minute response time. The deficiencies highlight a systemic issue in the facility's ability to provide timely and adequate care for residents' hygiene needs. Both the failure to provide scheduled baths and the delayed response to incontinence care indicate lapses in staff coordination and adherence to care plans. These deficiencies were confirmed through multiple interviews with residents and staff, as well as a review of clinical records and care plans.
Insufficient CNA Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient certified nursing assistant (CNA) staff to meet the needs of residents, resulting in inadequate care for four out of six residents reviewed. The facility's PBJ Staffing Data Report for Fiscal Year 2024 Quarter 1 revealed a 1-star staffing rating. On multiple dates, the facility had only one CNA assigned to each hall, and in some instances, there was no shower aide available, leading to missed baths and delayed care for residents. For example, Resident #1, who required partial assistance with eating and was dependent on staff for bathing, did not receive a whirlpool bath on days when hospice did not bathe her. Resident #2, who was dependent on staff for toileting and bathing, often received bed baths instead of showers due to insufficient staff to assist with the shower gurney. Resident #R4, who required a Hoyer Lift for transfers, experienced significant delays in receiving incontinence care and missed baths due to short staffing. On one occasion, her call light was on for two hours before she received assistance after a bowel movement. Similarly, Resident #R5, who was always incontinent and dependent on staff for bathing, reported not having had a bath in five days. CNAs confirmed that they were unable to complete their tasks timely due to the high workload and insufficient staffing, leading to residents waiting longer than two hours for incontinence care and missing scheduled baths. Interviews with staff members revealed that the facility was consistently understaffed, with CNAs responsible for more residents than they could adequately care for. The Director of Nursing (DON) confirmed that there were not enough CNAs scheduled to care for the residents on multiple occasions, and the facility had lost four CNAs in the last two weeks due to the workload. The lack of sufficient staffing led to residents not receiving timely care, including missed baths, delayed incontinence care, and inadequate assistance with daily living activities.
Inadequate Supervision During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision during a Hoyer Lift transfer for a resident diagnosed with Hemiplegia and Hemiparesis following a cerebral infarction. The resident's lifting plan explicitly required the assistance of two staff members for Hoyer Lift transfers. However, an observation revealed that a CNA independently transferred the resident using the Hoyer Lift, contrary to the specified requirement. The CNA confirmed that she performed the transfer alone and acknowledged that two staff members should always be present during such transfers. Further interviews with other staff members, including the CNAS and the DON, corroborated that the facility's policy mandates the presence of two staff members during Hoyer Lift transfers to prevent accidents. The DON reviewed the resident's clinical record and confirmed the necessity of two staff members for the resident's transfers. Despite this policy, the observed transfer was conducted by a single CNA, indicating a lapse in adherence to the facility's safety protocols.
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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) |
|---|---|---|---|---|
| Heritage Manor Of Baton Rouge Ii | 0 mi | ★★★★★ | 5 | 0 |
| Jefferson Manor Nursing And Rehab Ctr, Llc | 0.7 mi | ★★★★★ | 5 | 0 |
| Ollie Steele Burden Manor | 1.6 mi | ★★★★★ | 10 | 0 |
| White Oak Post Acute Care | 1.6 mi | — | 12 | 1 |
| Center Point Health Care And Rehab | 1.8 mi | ★★★★★ | 8 | 0 |
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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.