Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Ollie Steele Burden Manor during CMS and state inspections, most recent first.
Improper food storage and missing kitchen temperature documentation were identified during a kitchen tour and record review. Open food items were found in the walk-in refrigerator, dry storage, and freezer without proper labels, dates, or sealing, and the Dietary Mgr confirmed they were not stored correctly. Review of logs also showed missing documentation for meal temps, dishwashing machine temps, and 3-compartment sink temps and sanitation levels, which the Dietary Mgr and ADM confirmed should have been recorded.
Infection control practices were not consistently followed. A CNA caring for a resident on contact and droplet precautions exited and re-entered the room while still wearing PPE and later placed a used KN95 in her pocket. Two LPNs administered Humalog insulin to two residents without sanitizing the insulin pen stopper before attaching the needle. The facility also could not provide documentation showing its infection prevention and control policies were reviewed annually.
Incomplete Medicare Liability Notices: Two residents had incomplete ABN forms for non-covered skilled services. The forms were signed but left blank for the services that may not be covered, the estimated cost, and the option selection, and the required SNF ABN form was not provided. An LPN stated she verbally notified the resident or representative and obtained signatures, but confirmed she did not discuss payment liability or complete the forms correctly; the ADM also confirmed the forms were incomplete.
A resident with TIA, L hemiplegia/hemiparesis, and moderate cognitive deficits was identified as high risk for falls on admission, with dependence for transfers and no walking performed due to safety concerns. Although staff confirmed he was a high fall risk due to physical impairments and impulsivity, his care plan did not include fall risk as a focus or any fall-prevention interventions, and he reported several near-falls since admission.
Care Plan Not Updated for Mechanical Lift Transfers: A resident with CVA-related hemiplegia was documented as dependent for transfers and later required a mechanical lift, but the care plan was not revised to reflect that change. Therapy communication noted mechanical lift transfers, staff observed the resident being transferred with a mechanical lift, and both the MDS staff member and DON confirmed the care plan still did not include the updated transfer requirement.
Failure to Prime Insulin Pen Needles: Two residents received Humalog insulin from LPNs who applied the pen needles, dialed the ordered sliding-scale doses, and administered the injections without priming the needles first. Both residents had DM diagnoses, and both LPNs confirmed they did not prime the pens because they believed it was not needed. The DON stated insulin pen needles should be primed per the manufacturer’s guidelines.
A resident with pulmonary HTN and CHF had O2 ordered at 2 L/min via NC PRN, and staff observed the resident receiving O2 with the tubing and humidification bottle not labeled or dated on repeated checks. An LPN confirmed the equipment was not labeled or dated and said it should have been changed on the prior night shift; the DON also stated the tubing and humidification bottle should have been labeled and dated.
Medication storage and labeling were deficient when two opened Humalog Kwik pens for two residents were found on a cart without open dates, and an LPN stated she did not label insulin pens and was unaware they expire 28 days after opening. In addition, an opened bottle of Fish Oil 1000 mg was found expired and still available for use in a med room; the DON confirmed both issues.
Improperly Covered Outdoor Trash Dumpsters: The facility failed to keep outdoor trash dumpsters covered when not in use. During an observation, one dumpster had one lid open and the other dumpster had both lids open while both were half full of trash. S4DM and S1ADM both confirmed the lids should be kept closed when not in use.
A resident receiving hospice care had an outdated hospice POC in the hospice binder, and the facility had not clearly assigned an IDT member to coordinate care with hospice staff. The DON said the floor nurse was responsible for keeping the binder current, while an LPN and the CSR stated they were unaware of any assigned staff member responsible for ensuring the hospice binder contained the most current POC.
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) before discontinuing Medicare Part A services for three residents. The facility's policy requires a NOMNC to be given when services end, but this was not done for these residents. A staff member confirmed the oversight, citing a lack of awareness of the requirement.
The facility failed to complete and transmit discharge MDS assessments for several residents. Three residents were discharged without their assessments being opened, completed, or transmitted, and another resident's assessment was incomplete and not transmitted. The facility's MDS nurse and DON confirmed these deficiencies, which violated the facility's policy and federal regulations.
The facility failed to complete quarterly MDS assessments for three residents as required by regulations. An MDS nurse and the DON confirmed that assessments were not completed every three months, as per policy. This deficiency was identified during a review of residents' records.
A resident with Schizophrenia was admitted to the facility with an expectation of staying less than 30 days, exempting them from a Level II PASARR. However, when the stay extended beyond 30 days, the facility failed to complete the required Level II PASARR evaluation. The DON and Social Services Worker acknowledged the oversight, confirming the resident met the criteria for a Level II PASARR, but it was not submitted to the state authority.
The facility did not post complete nurse staffing data as required, omitting the resident census from the daily staffing sheet. This was observed outside the DON's office, and the DON confirmed the omission, acknowledging it should have been included. This oversight could potentially affect any of the 20 residents in the facility.
Improper Food Storage and Missing Kitchen Temperature Documentation
Penalty
Summary
Food was not stored and prepared in accordance with professional food service standards in the facility kitchen. During an initial kitchen tour with the Dietary Manager, surveyors observed a large silver pan containing 14 individually wrapped sandwiches in the walk-in refrigerator that was not labeled or dated. In dry storage, multiple open food items were found without labels or dates, including sloppy joe mix, taco seasoning mix, tortillas, corn bread mix, dry gelatin mix, and four bags of dry pasta. In the walk-in freezer, a box containing 8 croissants was open and unsealed, and a package of mixed vegetables was open and not labeled or dated. The Dietary Manager confirmed these items were not properly stored and stated that all food items should be fully covered, labeled with the item name, opened date, and discard date. Surveyors also reviewed kitchen temperature logs and found missing documentation for dishwashing machine temperatures, 3-compartment sink temperatures, and meal temperatures on multiple dates. The missing entries included breakfast, lunch, and dinner documentation for the dishwashing machine, lunch documentation for the 3-compartment sink, and breakfast meal temperatures. The Dietary Manager stated he was responsible for reviewing the temperature logs weekly and confirmed that dietary staff should document each food's temperature before serving, as well as dishwashing machine temperatures and 3-compartment sink wash temperature, rinse temperature, and sanitation level with each meal service. The Administrator was informed of the findings and confirmed that opened food items should have been sealed, labeled, and dated, and that the required meal and sanitation temperature checks should have been recorded but were not.
Infection Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. One resident had COVID-19 and was on contact and droplet precautions. During an observation, a CNA entered the resident’s room wearing a gown, gloves, and layered masks, but exited the room without removing PPE, re-entered the room while still wearing the same PPE to handle meal items and assist with the meal, and then removed the gown, gloves, and surgical mask inside the room. After exiting, the CNA placed the KN95 mask in her pocket. The CNA later confirmed she should not have exited the room wearing PPE or placed the used mask in her pocket. The Infection Preventionist and DON also stated staff should remove PPE before exiting a room on transmission-based precautions and should not place a used mask in a pocket. The facility also failed to ensure insulin pen stoppers were sanitized before needle attachment for two residents receiving Humalog insulin. For one resident with type 2 diabetes mellitus with other circulatory complications, an LPN removed the insulin pen cap and attached the pen needle without sanitizing the rubber seal. For another resident with type 2 diabetes mellitus with diabetic polyneuropathy, a different LPN did the same and also did not sanitize the insulin pen stopper before attaching the needle. Both nurses confirmed they did not clean the pen stopper before administering insulin. The DON stated that if the manufacturer says to sanitize the insulin pen stopper prior to attaching the pen needle, nurses should clean it with an alcohol swab. The facility further failed to provide documented evidence that its Infection Prevention and Control Policies and Procedures were reviewed annually. The Infection Preventionist stated the interdisciplinary team, nurse consultant, and she reviewed and updated the infection control policies at least annually and throughout the year as needed, but she was unable to provide documentation of the annual review.
Incomplete Medicare Liability Notices
Penalty
Summary
The facility failed to inform residents or their legal representatives in writing of Medicare services that may not be covered and of their potential liability for payment for non-covered services. Based on record review, Resident #53’s Beneficiary Notification Review form showed the last covered day for Medicare Part A skilled services was 08/21/2025, and the resident remained in the facility. The Advance Beneficiary Notice of Non-coverage (CMS-R-131) for this resident was signed by the resident representative on 08/19/2025, but the form was incomplete because the sections for what Medicare services may not be covered, the estimated cost for the non-covered services, and the option choice were left blank. The required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (CMS-10055) for Medicare Part A services was not provided. Resident #54 had a Beneficiary Notification Review form showing the last covered day for Medicare Part A skilled services was 07/04/2025 and remained in the facility. The CMS-R-131 ABN for this resident was signed by the resident on 07/01/2025, but it was also incomplete, with blank sections for the services that may not be covered, the estimated cost, and the option choice. The CMS-10055 form for Medicare Part A services was not provided for this resident. During interviews, the LPN stated she verbally notified residents and/or responsible parties of the upcoming discharge from skilled services and had them sign the ABN forms, but she confirmed the forms were incomplete and that she did not discuss payment liability or have the resident or representative select an option. The ADM also reviewed the forms and confirmed they were incomplete and should have included the non-covered services, estimated cost, and resident or representative options.
Failure to Care Plan for High Fall Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was identified as high risk for falls. The resident was admitted with diagnoses including transient ischemic attacks and hemiplegia/hemiparesis affecting the left, non-dominant side. His admission MDS showed a BIMS score of 12, indicating moderate cognitive deficits, and Section GG showed he was dependent on staff for transfers and that walking was not performed due to his medical condition and/or safety concerns. The resident's fall risk evaluation dated 08/07/2025 showed a total score of 20, which indicated high fall risk, and the policy stated that prevention protocol should be initiated immediately and documented on the care plan. However, the current care plan did not feature fall risk as a focus and had no interventions established to prevent falls. The resident reported several near-falls since admission, and staff interviews confirmed he was considered a high fall risk due to residual physical impairments and impulsivity, had previously attempted to toilet independently, and should have been care planned for fall risk.
Care Plan Not Updated for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure Resident #21’s care plan was reviewed and revised after her transfer status changed to require a mechanical lift. Resident #21 was admitted with diagnoses including cerebral infarction and hemiplegia and hemiparesis affecting the left, non-dominant side. Her quarterly MDS with an ARD of 08/21/2025 showed she was dependent on staff for transfers, and her current care plan listed that she was dependent on staff for transferring, with the intervention dated 10/11/2024. A Therapy Communication form dated 11/05/2024, displayed above her bed, stated “Mechanical lift transfers.” During observation on 09/16/2025, Resident #21 was transferred from bed to wheelchair via mechanical lift by staff. The ROT confirmed she required a mechanical lift for transfers and stated therapy communicated changes verbally and through the Therapy Communication form. The MDS staff member reviewed the care plan and confirmed it had not been revised to include the mechanical lift requirement and should have been. The DON also reviewed the care plan and confirmed it had not been revised to reflect the need for mechanical lift transfers.
Failure to Prime Insulin Pen Needles
Penalty
Summary
The nursing facility failed to ensure that insulin pen needles were primed before insulin administration, as required by the manufacturer’s instructions and the facility’s insulin pen needle guidelines. The report states that the Humalog KwikPen instructions required priming before each injection by selecting 2 units, holding the pen with the needle pointing up, tapping to move air bubbles, and pushing the dose knob until insulin appeared at the needle tip. The facility’s own insulin pen needle guidance also directed staff to face the needle tip up, flick the pen to move bubbles to the top, and press the injection button until liquid flowed out through the needle tip. Two residents were observed receiving Humalog insulin without the pen needles being primed. One resident had Type 2 DM with other circulatory complications and a blood glucose level of 352 mg/dL when an LPN applied the insulin pen needle, dialed 8 units, and administered the insulin without priming. Another resident had Type 2 DM with diabetic polyneuropathy and a blood glucose level of 330 mg/dL when a different LPN applied the insulin pen needle, dialed 6 units, and administered the insulin without priming. Both LPNs confirmed during interview that they did not prime the insulin pen needles and stated they believed priming was not needed. The DON was informed and stated insulin pen needles should be primed per the manufacturer’s guidelines.
Respiratory Equipment Not Labeled or Dated
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards of practice for a resident with an order for oxygen at 2 liters per minute via nasal cannula as needed. The resident had diagnoses including pulmonary hypertension and congestive heart failure, and the care plan addressed shortness of breath with an intervention to check pulse oximetry and administer oxygen if the saturation was less than 95%. During observations, the resident was seen sitting in a wheelchair at the bedside with oxygen in place via nasal cannula flowing at 2 liters per minute, but the oxygen tubing and humidification bottle were not labeled or dated. This same condition was observed again the following day. An LPN confirmed the tubing and humidification bottle were not labeled or dated and stated they should have been changed on Saturday night shift. The DON also stated the oxygen tubing and humidification bottle should have been changed on Saturday night shift and should have been labeled and dated.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medications were not stored and labeled in accordance with accepted professional principles. During observation of Cart C with the LPN, two opened Humalog Kwik pens for Resident #2 and Resident #30 were found without an open date. The LPN stated she did not label insulin pens with the opened date and relied on the expiration date on the pen, and she was unaware that Humalog Kwik pens expire 28 days after opening. The DON stated nurses on the hall were responsible for checking medication carts for unlabeled medications and confirmed that insulin pens should be labeled with the date opened and used according to manufacturer guidelines. An additional medication storage issue was identified in Med Room A, where an opened bottle of Fish Oil 1000 mg with an expiration date of 06/2025 was observed available for use. The DON confirmed the bottle was expired and should have been discarded. The facility's medication storage policy stated medications were to be stored according to manufacturer recommendations and in a manner sufficient to ensure proper sanitation.
Improperly Covered Outdoor Trash Dumpsters
Penalty
Summary
The facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpsters. Review of the facility’s undated policy titled, Disposal of Garbage and Refuse, stated that containers and dumpsters shall be kept covered when not being loaded. During an observation of the facility’s two outdoor trash dumpsters with S4DM, one dumpster was seen with one of its two lids open and half full of trash, and the second dumpster was seen with both lids open and half full of trash. S4DM confirmed the observation and stated the dumpster lids should be kept closed when not in use. Later, S1ADM was informed of the open dumpster lids and also confirmed that the lids should be kept closed when not in use.
Hospice Coordination and Binder Documentation Deficiencies
Penalty
Summary
The facility failed to meet hospice requirements for Resident #4 by not designating a member of the interdisciplinary team to be responsible for working with hospice representatives to coordinate care between facility staff and hospice staff. Resident #4 was admitted to the facility on [DATE] and was admitted to a local hospice agency on 06/07/2025 with a certification period of 09/04/2025 through 12/02/2025. The resident’s Significant Change MDS with an ARD of 06/10/2025 indicated hospice care was in place. A review of Resident #4’s hospice plan of care on 09/17/2025 showed the hospice binder contained an outdated plan of care for the certification period of 06/06/2025 through 09/03/2025 rather than the current certification period. During interviews, the DON stated the floor nurse was responsible for ensuring the hospice binder contained current certification periods and plans of care. The LPN stated she was unaware it was her responsibility to ensure the hospice binder maintained the most current plan of care, and the CSR stated she was unaware any facility staff member had been assigned to ensure the hospice binder contained the most current plan of care. The CSR also stated she filed the certification period and plan of care in the clinical record but did not double check behind the hospice nurse to ensure the documents were current and up to date.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) prior to the discontinuation of Medicare Part A services for three residents. According to the facility's policy, a NOMNC, Form CMS-10123, should be provided to residents when Medicare-covered services are ending, regardless of whether the resident is leaving or staying in the facility. However, upon review, it was found that Residents #25, #228, and #229 did not receive this notice before their skilled nursing services were discontinued. Resident #25's Medicare Part A skilled services ended on 08/11/2024, Resident #228's on 09/18/2024, and Resident #229's on 10/09/2024. In an interview conducted on 10/30/2024, staff member S4MDS confirmed that she had not provided the NOMNC to these residents prior to their discharge from Medicare Part A services. She stated that she was unaware that the NOMNC should have been provided, indicating a lapse in adherence to the facility's policy regarding beneficiary notification.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure that each resident's discharge was properly encoded in an MDS assessment for three residents and that a discharge assessment was completed and transmitted for one resident. Specifically, Residents #7, #12, and #22 were discharged from the facility without their discharge MDS assessments being opened, completed, or transmitted. This was confirmed by the facility's MDS nurse and the Director of Nursing (DON), who acknowledged that these assessments should have been completed and transmitted according to the facility's policy and federal regulations. Additionally, Resident #6's discharge MDS assessment was opened but remained incomplete and was not transmitted. The MDS nurse and the DON confirmed that the discharge assessment for this resident was not completed or transmitted within the required timeframes. The facility's policy mandates that discharge assessments be completed within 7 days of discharge and transmitted within 14 days of completion, which was not adhered to in these cases.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that each resident was assessed using the quarterly review instrument at least once every three months, as required by federal and state regulations. This deficiency was identified for three residents out of eleven reviewed. Specifically, Resident #1 had a quarterly MDS assessment with an Assessment Reference Date (ARD) of June 20, 2024, but no subsequent assessment was completed after that date. Resident #19 had a quarterly MDS assessment with an ARD of May 28, 2024, and although an MDS was opened with an ARD of August 27, 2024, it was not completed. Similarly, Resident #20 had a quarterly MDS assessment with an ARD of June 25, 2024, and an MDS was opened with an ARD of September 24, 2024, but it was not completed. Interviews with facility staff, including an MDS nurse and the Director of Nursing (DON), confirmed that the quarterly MDS assessments for these residents were not completed as required. The MDS nurse acknowledged that the assessments should have been completed every three months and confirmed the oversight for Residents #1, #19, and #20. The DON also reviewed the assessments and confirmed that the quarterly MDS assessments were not completed on time, as per the facility's policy and regulatory requirements.
Failure to Complete Level II PASARR for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASARR) was completed for a resident with a diagnosis of Schizophrenia. The resident was admitted with the expectation of staying less than 30 days, which initially exempted them from requiring a Level II PASARR. However, when the resident remained in the facility beyond 30 days, the facility did not complete the necessary Level II PASARR evaluation and determination as required by their policy and state Medicaid rules. The Director of Nursing (S3DON) acknowledged that a Level II PASARR should have been completed once the resident's stay extended beyond 30 days. The Social Services Worker (S5SW), who was responsible for submitting the Level II PASARR, confirmed that the resident met the criteria for a Level II PASARR due to their Schizophrenia diagnosis but admitted that the submission had not been made to the appropriate state-designated authority. This oversight resulted in non-compliance with the facility's policy and state requirements for PASARR evaluations.
Failure to Post Complete Nurse Staffing Data
Penalty
Summary
The facility failed to post nurse staffing data on a daily basis, specifically omitting the total resident census, which is required by their policy. This deficiency was identified during an observation on October 29, 2024, at 11:15 a.m., when the daily staffing sheet posted outside the Director of Nursing's office did not include the resident census. The facility's policy, revised in August 2022, mandates that the resident census at the beginning of each shift be recorded on the staffing sheet. During an interview conducted shortly after the observation, the Director of Nursing confirmed that the resident census was missing from the staffing sheet and acknowledged that it should have been included. This oversight had the potential to affect any of the 20 residents residing in the facility.
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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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| Heritage Manor Of Baton Rouge Ii | 1.5 mi | ★★★★★ | 5 | 0 |
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| Jefferson Manor Nursing And Rehab Ctr, Llc | 1.7 mi | ★★★★★ | 5 | 0 |
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