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 Pines Retirement Center Of Baton Rouge during CMS and state inspections, most recent first.
Kitchen sanitation and milk temperature control failures: Surveyors observed a can opener with metal shavings and dried black residue, dirty ceiling vents, unsecured ceiling tiles with gray fluffy substance, and a steamer drip pan overflowing white liquid onto the table and floor. Dietary staff also placed milk on resident meal trays from the serving line while it was not on ice, and one container measured 43.2°F, above the stated 41°F limit.
Medication administration was not performed according to orders and manufacturer instructions. An LPN gave carvedilol to a resident with atrial fibrillation and HTN without checking the required HR first, another LPN administered an inhaled COPD medication without having the resident rinse and spit afterward, and an LPN gave Humalog by insulin pen without priming the needle first. The LPNs confirmed the actions, and the DON stated nurses were expected to follow the ordered and required steps.
Improperly Contained Garbage and Refuse in Dumpster Area: The facility failed to keep the dumpster area clean and properly contain garbage and waste. An observation found two AC window units, a mattress, a power chair, wooden crates and boxes, and scattered trash on the ground around two dumpsters. The DM, S5MS, and the ADM all observed and confirmed the condition, and S5MS stated he was responsible for keeping the area clean.
Call Light Not Kept Within Reach: A resident with hemiplegia, weakness, and impaired mobility was observed in bed with the call light on the floor at the foot of the bed and not within reach. The resident confirmed she could not reach it, and an LPN confirmed the call light should have been within reach. The DON also confirmed the call light should always be within the resident's reach and never on the floor.
Failure to Refer Resident With Mental Health Diagnosis for PASARR Level II: A resident with a documented schizoaffective disorder diagnosis was not referred for a PASARR Level II evaluation after the diagnosis was identified. The resident’s PASARR Level I did not reflect any mental health diagnoses, and the ADM acknowledged the resident should have been referred for a Level II review.
A resident admitted with a displaced intertrochanteric fracture of the left femur had an incomplete Comprehensive Person-Centered Care Plan for ADL needs. The care plan used placeholders instead of specific instructions for bed mobility, dressing, eating, personal hygiene/oral care, and transfers, and both the MDS nurse and RN coordinator confirmed it was incomplete.
Tube feeding supplies were not changed within required timeframes for a resident with dysphagia and a gastrostomy tube. The resident’s Jevity 1.5 feeding bag was observed hanging and later infusing with dates and expiration times not documented, brown dried formula inside the bottle, and a free water bag labeled for no more than 24 hours. An LPN stated she restarted an already spiked feeding bottle instead of using a new kit, and the DON confirmed staff should follow manufacturer guidelines for tube feeding solution and supplies.
Drugs and biologicals were not stored in accordance with accepted professional principles when Cart A was observed with 13.5 loose pills on the bottom of its drawers. The RNCO stated nurses should check medication carts daily for loose medications and confirmed the pills should not have been loose. The DON also stated she expected daily cart checks, including looking for loose meds in the drawers, and confirmed meds should not be loose in the cart.
An LPN inaccurately documented a PEG feeding bag change as completed on the MAR even though she did not perform the task. An observation later found the tube feeding solution still infusing with an expired written date, and the DON confirmed staff should not chart care as completed unless it was actually done.
Nurse Staffing Data was not posted correctly on the bulletin board. The form showed CNA, LPN, and RN totals and actual hours, but it did not document the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. An ADM reviewed the form and confirmed the missing per-shift documentation.
A nurse administered insulin to a resident using a vial labeled for another resident, despite both residents having their own physician-ordered insulin and the correct vial being available. The LPN acknowledged the error, and the DON confirmed that each resident should have their own insulin and that borrowing between residents is not permitted.
A nurse prepared and nearly administered 5 units of regular insulin to a resident with diabetes, despite the physician's sliding scale order requiring only 2 units based on the resident's blood glucose level. The error was identified before administration when another nurse reviewed the syringe and confirmed the incorrect dosage, in violation of facility policy requiring accurate medication administration.
Staff did not follow Enhanced Barrier Precautions by failing to wear a gown while emptying a urinal for a resident with an indwelling device, and clean linens were transported pressed against staff clothing instead of in a clean linen bag, contrary to facility policy.
The facility failed to update and implement care plans for two residents. One resident's care plan did not reflect the use of a geri chair, despite its necessity due to poor trunk control. Another resident experienced unwitnessed falls, and the required neurological assessments were not completed for the full duration. Additionally, the care plan was not revised after a fall resulting in injury. Staff confirmed these deficiencies in care plan management.
The facility failed to report and investigate multiple allegations of verbal and physical abuse involving residents and staff. Incidents were not reported to the State Survey Agency within the required timeframe, and investigations were not conducted promptly. The administrator did not implement corrective actions, leaving involved staff in their positions without addressing the allegations. This led to an Immediate Jeopardy situation, indicating a serious risk to resident safety.
The facility failed to prevent and report verbal abuse incidents involving residents and staff, leading to multiple cases of yelling, cursing, and threatening behavior. Despite reports from residents and staff, the administration did not take timely action to address the allegations or remove involved staff from resident care duties, allowing the abusive behavior to continue.
The facility failed to protect residents from verbal and mental abuse, involving multiple staff members who yelled, cursed, and intimidated residents. Despite being aware of these incidents, the administration did not take immediate action to remove the involved staff or provide additional training, allowing the abusive behavior to persist and creating an unsafe environment for residents.
The facility failed to employ a certified dietary manager, as the current dietary manager, hired a month ago, lacked the necessary certification. A consultant dietitian worked part-time, and the facility administrator confirmed the deficiency. This issue potentially affected 56 residents consuming food from the kitchen.
The facility failed to adhere to professional standards for food service safety by not labeling opened food containers in the kitchen and dry storage areas. This deficiency was confirmed through observations and interviews with staff, affecting the safety of food consumed by 56 residents.
A resident with Adjustment Disorder exhibited aggressive behaviors towards staff and other residents, but the facility failed to notify the psychiatric NP as required by policy. Despite the administration and DON being aware of the behaviors, the NP was not informed, leading to a significant oversight in care management.
The facility failed to update care plans for two residents, one requiring a two-person mechanical lift for transfers and another exhibiting verbally aggressive behavior. Staff interviews confirmed the lack of necessary interventions in the care plans, indicating a lapse in documentation and communication.
A resident with HIV did not receive her prescribed medication due to a failure in communication and order management. Despite discharge instructions from a rehabilitation center, the medication was not documented in the MAR, and staff were unaware of the need to reorder it. Interviews revealed that the LPN discontinued the medication without an order, and the DON was unaware of the discharge instructions.
The facility failed to provide direct care staff with necessary behavioral health training, including Crisis Prevention Interventions (CPI), for a resident with Adjustment Disorder who exhibited aggressive behaviors. Despite being aware of the resident's condition, the facility did not ensure staff competency, potentially affecting all residents.
A facility failed to accurately assess a resident's discharge status. The resident was transferred to a hospital, but the Discharge MDS incorrectly indicated a discharge to home/community. The RN responsible for MDS assessments and the DON confirmed the error.
A facility failed to properly disinfect a glucometer between uses, as an LPN used an incontinence wipe without disinfectant instead of the required healthcare disinfectant wipe. This was observed during a blood glucose check on a resident, and both the LPN and the DON confirmed the improper cleaning method, which violated the facility's infection control policy.
The facility failed to support resident self-determination and choice, affecting three residents. A resident was not allowed to visit another resident, and both were told to stay in a room or leave the hall by an LPN. Another resident's request for staff to wear gloves during medication administration was ignored, leading to medication refusal. The facility's policy on resident rights was not upheld.
A resident with cerebral palsy and muscle weakness was injured during a transfer when a CNA attempted to use a mechanical lift alone, contrary to facility policy requiring two staff members. The CNA leaned on the resident's leg, causing a fracture. The resident's care plan lacked specific transfer interventions, contributing to the incident.
A facility failed to ensure nursing staff had the necessary competencies for safe resident transfers. A resident with cerebral palsy and other conditions required a two-person assist mechanical lift transfer, but was transferred by one CNA while another observed, contrary to policy. The care plan lacked specific transfer assistance documentation, and staff confirmed the requirement for two-person transfers.
The facility failed to provide a clean and safe environment, as observed in a resident's room and common areas. A resident's mattress and blanket were found soiled, and common areas had urine odors and stains. Interviews revealed that housekeeping was unavailable overnight, leaving nursing staff responsible for cleaning spills. The Administrator confirmed the expectation for CNAs to maintain cleanliness after hours.
The facility failed to implement physician's orders for two residents. One resident did not receive scheduled MRIs due to a lapse in scheduling after the responsibility was transferred to the facility. Another resident, with respiratory issues, was incorrectly administered 10 liters of oxygen instead of the ordered 4 liters, due to misinformation during a morning report. These actions led to non-compliance with the residents' care plans.
A resident with HIV did not receive their prescribed Biktarvy medication because it was never filled. Instead, nursing staff borrowed the medication from another resident, violating the facility's medication administration policy. Interviews revealed a lack of communication and awareness among staff about the medication's unavailability.
The facility failed to provide essential medications to two residents, resulting in a deficiency. A resident with low back pain and gastroesophageal reflux disease did not receive Nexium and Norco due to unavailability, while another resident with HIV disease lacked access to Biktarvy. The facility's policy mandates accurate medication management, but a breakdown in communication and coordination led to these deficiencies.
A facility failed to ensure proper PPE use, as a CNA did not wear a gown while changing a resident's soiled brief, despite the resident being on Enhanced Barrier Precautions for MDRO prevention. The facility's policy requires gowns and gloves for such activities, but this was not followed, as confirmed by the DON.
The facility failed to maintain an effective pest control program, leading to the presence of pests in resident rooms. Observations revealed live and dead roaches in multiple rooms, with residents and staff confirming daily sightings. Interviews indicated that not all rooms were treated regularly, and the facility's administrator acknowledged the issue. This deficiency affected the living conditions of 67 residents.
A resident with severe cognitive impairment and multiple medical conditions experienced low blood pressure and increased confusion. Despite these changes, the facility failed to notify the physician or document the notification, as required by policy. Interviews revealed that nurses were aware of the abnormal vital signs but did not communicate them to the physician, leading to a deficiency in compliance.
A facility failed to document the reason for a resident's transfer to the hospital in the medical record, as required by their policy. The Emergency Transfer Log showed the resident was transferred for a medical reason and did not return, but the Nurses' Notes lacked documentation explaining the transfer. The DON confirmed the absence of documentation, acknowledging it should have been recorded.
A facility failed to ensure proper management of enteral feeding for a resident with Dysphagia and Gastrostomy Status. The resident's feeding solution bag was not changed for over 24 hours, and an opened container of the solution was found unlabeled in the room. Staff confirmed these oversights, indicating a lapse in protocol adherence.
A resident with severe cognitive impairment and multiple diagnoses had several medications not documented as administered in their MAR. Interviews with nursing staff confirmed the medications were given but not recorded, leading to a deficiency in maintaining accurate medical records.
A resident with a diabetic foot ulcer missed a scheduled follow-up appointment at an outpatient wound clinic due to a lack of documentation and scheduling oversight by the facility. The resident, who was cognitively intact, had specific physician orders for wound care that included attending the clinic. Interviews with staff revealed that the appointment was not documented on the facility calendar, and the after-visit summary was missing, leading to the missed appointment.
The facility failed to ensure a clean and safe environment, with Room A found unclean and Room B having stained ceiling tiles. The DON confirmed the issues, including unaddressed cleanliness and maintenance problems, and the administrator acknowledged the need for daily cleaning and tile replacement.
The facility failed to store food properly, as observed during a kitchen tour. Open bags of sugar, flour, and rice were found in bulk storage containers with lids left open, and a paper cup was found in the sugar. Staff confirmed that these practices did not meet professional standards for food service safety.
Kitchen sanitation and milk temperature control failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food service safety standards. During an initial kitchen tour, surveyors observed a can opener with a large amount of metal shavings and a dried black substance at the base, five ceiling vents with a moderate amount of black substance, one large ceiling vent near the walk-in cooler with a large amount of brown fluffy substance, one unsecured ceiling tile above the steam table, and another ceiling tile above the steam table with a string of gray fluffy substance hanging down. The steamer was also observed leaking a white liquid substance into a drip pan that had overflowed onto the table and floor underneath. The dietary manager confirmed these observations and stated the can opener should have been cleaned after each use, the ceiling vents should have been cleaned, the ceiling tiles should have been secured and free of the gray fluffy substance, and the drip pan should have been emptied to prevent overflow. On a follow-up kitchen observation, dietary staff were seen performing temperature checks of milk from plastic containers on the serving line. Four 8 oz. plastic containers of milk were on the serving line prep table, not on ice, and were being placed on resident meal trays. One milk temperature was measured at 43.2 degrees Fahrenheit. The dietary manager confirmed the milk was available to be served for resident consumption and stated dairy products should have been maintained at or below 41 degrees Fahrenheit. The administrator was informed of the observations and confirmed that kitchen staff were expected to keep the kitchen clean and sanitary and that dairy products should be kept at or below 41 degrees Fahrenheit for resident safety.
Medication Administration Not Performed per Orders and Instructions
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and manufacturer instructions during observed medication passes. Resident #33, who had diagnoses including atrial fibrillation and essential hypertension, had an order for carvedilol 3.125 mg twice daily with instructions to hold the medication for a heart rate less than 50. During observation, an LPN administered carvedilol without checking the resident’s heart rate first. The LPN later confirmed she did not check the heart rate as ordered, and the DON stated nurses were expected to check a resident’s heart rate before giving the medication. The facility also failed to follow manufacturer directions for an inhaled medication and insulin pen use. Resident #53, who had COPD, was observed receiving fluticasone furoate-vilanterol 100-25 mcg inhalation, but the LPN did not instruct or assist the resident to rinse and spit after the dose as directed in the medication insert. Resident #19, who had type 2 diabetes mellitus with hyperglycemia, was observed receiving Humalog 15 units by insulin pen; the LPN applied the needle, dialed the dose, and administered the insulin without priming the pen needle first. In both instances, the LPNs confirmed the actions and stated they should have followed the required steps, and the DON stated nurses were expected to do so.
Improperly Contained Garbage and Refuse in Dumpster Area
Penalty
Summary
The facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpster area. During an observation with the DM, two air conditioner window units, one mattress, one power chair, multiple wooden crates and boxes, and scattered trash were seen discarded on the ground around two dumpsters. The DM observed and confirmed the condition of the dumpster area and stated that S5MS was responsible for keeping it clean. S5MS later stated he was responsible for keeping the dumpster area clean, observed the findings, and confirmed the area should have been kept clean but was not. The ADM also observed and confirmed the same findings and stated that S5MS was responsible for keeping the dumpster area clean.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to reasonably accommodate a resident's needs by not keeping the call light within reach for Resident #5. The facility's policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach and positioned within easy reach of the resident. Resident #5 was admitted with diagnoses including unsteadiness on feet, hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, difficulty walking, generalized muscle weakness, and other lack of coordination. Resident #5's care plan directed staff to assist with transfers, encourage use of the bell to call for assistance, anticipate and meet needs, and ensure the call light was within reach and respond promptly to requests for assistance. During observations, the resident was found lying in bed with the call light on the floor at the foot of the bed and not within reach. The resident confirmed she could not reach it, and an LPN later confirmed the call light was on the floor and should have been within reach. The DON was notified and confirmed the call light should have been within reach at all times when the resident was in her room and should never have been on the floor.
Failure to Refer Resident With Mental Health Diagnosis for PASARR Level II
Penalty
Summary
The facility failed to ensure that a resident with an identified mental health diagnosis was referred for a PASARR Level II evaluation. Resident #4 was admitted with diagnoses including Type 2 Diabetes Mellitus, and the clinical record also showed a diagnosis of Schizoaffective Disorder, Bipolar Type with an onset date of 10/01/2020. Review of the resident’s PASARR Level I dated 05/06/2013 showed no mental health diagnoses were selected, and there was no evidence that a Level II evaluation and determination had been submitted after the schizoaffective disorder diagnosis was identified. During interview, the administrator reviewed the resident’s PASARR Level I and diagnoses and stated that the resident had Schizoaffective Disorder, Bipolar Type acquired on 10/01/2020 and should have been referred for a PASARR Level II evaluation.
Incomplete Comprehensive Person-Centered Care Plan for ADL Needs
Penalty
Summary
The facility failed to develop a Comprehensive Person-Centered Care Plan for 1 of 1 resident reviewed for ADL care, Resident #53. The resident was admitted with diagnoses including a displaced intertrochanteric fracture of the left femur. Review of the current care plan showed an ADL self-care performance deficit related to activity intolerance, but the interventions were incomplete and contained placeholders instead of specific care instructions for bed mobility, dressing, eating, personal hygiene/oral care, and transfer assistance. The care plan listed that the resident required assistance with turning and repositioning, dressing, eating, personal hygiene/oral care, and was totally dependent for transfers, but did not specify the exact level of assistance, number of staff, frequency, or resident abilities as required. During interviews, the MDS nurse and RN coordinator both reviewed the care plan and confirmed that it was incomplete and should have been completed.
Tube Feeding Supplies Not Changed Within Required Timeframes
Penalty
Summary
Resident #8 had diagnoses including dysphagia following cerebral infarction and a gastrostomy status. The physician orders directed Jevity 1.5 at 45 mL/hr via gastrostomy tube daily and to change the PEG feeding bag every 24 hours. During observation, the resident’s tube feeding solution was found spiked and hanging in the room while not infusing, and later was observed infusing with the same bottle still dated without a time and with a written expiration date also lacking a time. The tube feeding solution bottle label stated it could hang up to 48 hours after initial connection, and the free water bag label stated it should not be used for greater than 24 hours. The tube feeding solution bottle was observed with brown, dried formula inside it, and the free water bag was also labeled with a 24-hour limit. An LPN stated she cared for Resident #8 when the resident returned to the facility and initiated the already spiked tube feeding solution bottle that had been hanging, confirming that a new tube feeding solution kit should have been used but was not. The DON later observed the resident’s tube feeding solution infusing with the dated label and expired written date and confirmed nursing staff should follow manufacturer guidelines regarding tube feeding solution and supplies.
Loose Pills Found in Medication Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with currently accepted professional principles when Cart A was found to contain loose pills in the bottom of its drawers. The facility’s undated Medications-Storage policy stated that drugs and biologicals shall be stored in a safe, secure, and orderly manner and in the packing, containers, or other dispensing systems in which they are received. During an observation with the RNCO, thirteen and a half loose pills were seen on the bottom of Cart A’s drawers. The RNCO stated nurses should check medication carts daily for loose medications and confirmed the pills should not have been loose in the cart. The DON was later informed of the observation and stated she expected nursing staff to perform daily medication cart checks, including checking for loose medications in the drawers, and confirmed medications should not be loose in the cart.
Inaccurate MAR Documentation for Tube Feeding Care
Penalty
Summary
The facility failed to ensure that Resident #8’s Medication Administration Record (MAR) was accurately documented for tube feeding care. Resident #8 was admitted with diagnoses including dysphagia following cerebral infarction and later had a diagnosis of gastrostomy status. The physician order required the gastrostomy feeding bag to be changed every 24 hours, and the MAR likewise directed staff to change the PEG feeding bag every 24 hours. Review of the MAR showed the task documented as completed at 5:00 a.m. by an LPN, but an observation later that morning found tube feeding solution spiked and hanging in the resident’s room and still infusing. The tube feeding bottle was dated and had a written expiration date that had already passed. During interview, the LPN stated she had provided care to the resident during the relevant shift but did not change the tube feeding solution bottle that morning, and acknowledged she documented the task as completed even though it was not done. The DON later reviewed the MAR and confirmed nurses should not document tasks as completed unless they complete them.
Nurse Staffing Data Not Posted Per Shift
Penalty
Summary
Post nurse staffing information was not posted correctly each day. Based on record review, observation, and interview, the facility failed to ensure the posted nurse staffing data included the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift. Review of the Nursing Staffing Data form dated 09/08/2025 showed a resident census of 61 and listed totals for CNA, LPN, and RN staff, along with actual hours worked, but the information was not documented per shift. During an observation at 10:15 a.m., the bulletin board outside the Dining Room displayed the Nurse Staffing Data form dated 09/08/2025, and the required total number and actual hours worked for licensed and unlicensed staff directly responsible for resident care were not documented per shift. During an interview at 10:30 a.m., S1ADM reviewed the form and confirmed that the total number and actual hours worked for licensed and unlicensed staff directly responsible for resident care were not documented per shift.
Medication Administration Error: Insulin Borrowed Between Residents
Penalty
Summary
Nursing staff failed to meet professional standards of quality by administering medication intended for one resident to another. Specifically, a Licensed Practical Nurse (LPN) was observed withdrawing regular insulin from a vial labeled for one resident and administering it to a different resident. The facility's policy clearly states that medications ordered for a particular resident may not be administered to another resident unless permitted by state law, facility policy, and approved by the Director of Nursing Services. The LPN acknowledged that the insulin vial used belonged to a different resident and confirmed that the correct insulin vial for the intended recipient was available in the medication room at the time. The incident involved two residents, both with Type 2 Diabetes Mellitus and individual physician orders for regular insulin with specific sliding scale instructions. The LPN did not follow the required procedure of verifying the correct medication for the correct resident, as outlined in the facility's medication administration policy. The Director of Nursing confirmed that each resident had their own insulin vial and that emergency stock was available if needed, emphasizing that staff should not use one resident's medication for another.
Significant Medication Error in Insulin Administration
Penalty
Summary
A deficiency occurred when a nurse failed to accurately prepare and administer insulin according to a physician's sliding scale order for a resident with Type 2 Diabetes Mellitus and Diabetic Neuropathic Arthropathy. The nurse was observed withdrawing 5 units of regular insulin from a multi-dose vial, despite the resident's blood glucose reading requiring only 2 units as per the sliding scale. The nurse initially stated she had drawn up 2 units, but upon review by another nurse, it was confirmed that 5 units had been prepared. The facility's policy requires that medications be administered as prescribed, with the individual administering the medication verifying the correct dosage, resident, medication, time, and route. The Director of Nursing confirmed that preparing 5 units when only 2 units were ordered was not acceptable practice. This medication error was identified through observation, interview, and record review, and had the potential to affect all residents in the facility who receive medications.
Failure to Follow Enhanced Barrier Precautions and Proper Linen Transport
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program as required by its own policies and national standards. Specifically, staff did not use proper personal protective equipment (PPE) when performing high-contact resident care activities. During an observation, a certified nursing assistant (CNA) entered a resident's room, where an Enhanced Barrier Precaution (EBP) sign was posted, and donned only gloves but not a gown before removing and emptying the resident's urinal. The resident in question had an open fracture of the right lower leg with an external fixator and was under physician orders for Enhanced Barrier Precautions due to the presence of an indwelling medical device. Additionally, staff failed to transport clean linens in a manner that would prevent the spread of infection. A CNA was observed removing clean linen from a hallway cart and carrying it pressed against her clothing while proceeding to a resident's room, instead of using a clean linen bag as required by facility policy. Interviews with staff and the Director of Nursing confirmed that these actions were not in compliance with established infection control procedures, including the use of gowns for high-contact activities and proper linen transport protocols.
Failure to Update and Implement Care Plans for Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented for two residents. For one resident, the care plan was not updated to reflect the use of a geri chair, despite observations and staff interviews confirming its necessity due to the resident's poor trunk control. The resident was observed using the geri chair, but the care plan did not document this intervention, which was acknowledged by the staff responsible for updating care plans. Another resident experienced multiple unwitnessed falls, and the facility did not implement the required neurological assessments for the full 72 hours as outlined in the care plan. Additionally, the care plan was not revised to include a fall that resulted in a laceration above the resident's left eyebrow. Staff interviews confirmed that the care plan should have been updated to reflect these incidents and that the necessary interventions were not carried out as required.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report allegations of verbal and physical abuse to the State Survey Agency within the required timeframe for five residents. Specifically, incidents involving verbal abuse by staff members towards residents were not reported immediately, as required by policy. For instance, Resident #52 experienced verbal abuse from two CNAs, which was not reported to the administrator until 20 days after the incident. Similarly, Resident #46 witnessed and reported verbal abuse by a CNA towards Resident #52, but the administrator did not report or investigate the incident until 10 days later. Additionally, the facility did not report the results of investigations within five working days, nor did it implement appropriate corrective actions for the abuse allegations. The administrator failed to conduct timely investigations or report findings to the State Agency, leaving the involved staff members in their positions without any corrective measures. This lack of action persisted despite multiple reports of abuse from residents and staff, including an incident where Resident #42 felt threatened by an LPN and another where Resident #35 allegedly pushed Resident #51. The facility's policy on abuse, neglect, and exploitation was not adhered to, as evidenced by the failure to report and investigate abuse allegations promptly. The administrator acknowledged the responsibility for reporting and investigating these incidents but did not take the necessary steps to address the allegations. This resulted in an Immediate Jeopardy situation, indicating a serious risk to resident safety due to the facility's inaction.
Failure to Prevent and Report Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled its resources to be used effectively and efficiently to maintain the highest practicable well-being of each resident. Specifically, the facility did not have an effective system in place to prevent verbal and mental abuse, as evidenced by multiple incidents involving residents and staff. Several residents reported being subjected to verbal abuse by staff members, including yelling, cursing, and threatening behavior. These incidents were not reported to the State Survey Agency within the required timeframe, and no immediate corrective actions were taken to protect the residents from further abuse. The report highlights specific incidents involving residents who were cognitively intact and able to report the abuse they experienced. For instance, one resident reported that two CNAs yelled, cursed, and pointed fingers at him, which was witnessed by other staff members who did not intervene. Another resident witnessed a CNA cursing at a fellow resident in the hallway, and yet another resident reported being intimidated and verbally abused by an LPN. Despite these reports, the facility's administration failed to take timely action to address the allegations or remove the involved staff from resident care duties. The facility's administration, including the Administrator and the Director of Nursing, did not report the incidents to the appropriate authorities or conduct thorough investigations. The lack of immediate response and failure to implement corrective measures allowed the abusive behavior to continue, placing residents at risk of further harm. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the continued presence of staff involved in the incidents and the absence of additional training or monitoring to prevent recurrence.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse, affecting three out of seven residents reviewed for abuse. The incidents involved staff members yelling, cursing, and intimidating residents. For instance, two CNAs were reported to have surrounded a resident in a wheelchair, yelling and cursing at him, which made the resident feel unsafe. Another CNA was reported to have yelled and cursed at the same resident in the hallway, and an LPN was accused of intimidating another resident by demanding she leave the hall. These actions were witnessed by multiple staff members, yet the facility administration did not take immediate action to remove the involved staff from resident care or provide additional training. The incidents continued over several weeks, with staff members repeatedly engaging in abusive behavior towards residents. Despite being aware of these incidents, the facility's administration failed to intervene effectively. The Director of Nursing (DON) was present during one of the altercations but did not intervene, and the Administrator did not remove the involved staff from their duties or provide necessary training on de-escalation techniques. This lack of action allowed the abusive behavior to persist, creating an environment where residents felt threatened and unsafe. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the continued presence of staff who engaged in abusive behavior. The administration's failure to act promptly and decisively in response to reports of abuse contributed to an immediate jeopardy situation for the residents involved. The facility's inaction and inadequate response to the incidents of abuse resulted in a potential for more than minimal harm to the other residents residing in the facility.
Lack of Certified Dietary Manager in Food and Nutrition Service
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service, specifically by not having a certified dietary manager on staff. This deficiency was identified during interviews and record reviews. An interview with the dietary manager revealed that he was hired a month ago and had not received a dietary manager certification. Additionally, a consultant dietitian was employed part-time, working only 20 hours per week, and was not a full-time employee. The facility administrator confirmed that the dietary manager lacked the necessary certification, which was required for the position. This deficiency had the potential to affect the 56 residents who consumed food from the kitchen.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect 56 residents who consumed food from the kitchen. During an observation of the kitchen food preparation area, several opened containers of spices and other food items, such as parsley flakes, celery salt, ground cinnamon, lemon juice, and brown sugar, were found to be unlabeled. Additionally, in the dry storage area, a 50lb bag of white granular sugar and a 25lb bag of brown rice were also found opened and unlabeled. Interviews conducted with the dietary manager (S9DM) and the administrator (S1ADM) confirmed that all opened containers should have been labeled with the open date, but they were not. This oversight in labeling opened food containers was identified as a deficiency in the facility's food storage practices.
Failure to Notify Physician of Resident's Aggressive Behaviors
Penalty
Summary
The facility failed to notify the physician when a resident exhibited aggressive behaviors towards staff and other residents. The facility's policy requires the nurse supervisor or charge nurse to inform the resident's attending physician or on-call physician of any significant changes in the resident's physical, emotional, or mental condition. However, there was no documentation indicating that the psychiatric nurse practitioner (NP) was informed of the resident's aggressive behaviors from mid-August to early October 2024. The resident in question was diagnosed with Adjustment Disorder, Unspecified, and was cognitively intact as per the Quarterly Minimum Data Set (MDS) assessment. Despite the resident's aggressive behaviors being known to the facility's administration and director of nursing, the psychiatric NP was not made aware of these issues. This lack of communication resulted in the NP being unaware of the resident's threatening behavior towards staff, which was a significant oversight in the resident's care management.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents were reviewed and revised appropriately, leading to deficiencies in their care. Resident #5, who was admitted with conditions such as Cerebral Palsy and Muscle Weakness, was dependent on staff for transfers and other activities of daily living (ADLs). However, the care plan did not document the necessary interventions for his transfer status, specifically the requirement for a two-person mechanical lift transfer. This oversight was confirmed during an interview with facility staff, who acknowledged the absence of this critical information in the care plan. Similarly, Resident #52, admitted with an Adjustment Disorder, exhibited verbally aggressive behavior. Despite this, the care plan lacked updated interventions to address these behaviors. The staff responsible for the Minimum Data Set (MDS) and care plan revisions were unaware of the resident's behavioral issues, indicating a lapse in communication and documentation. This deficiency was also confirmed during staff interviews, highlighting the need for regular and thorough review and revision of care plans to ensure they reflect the current needs and conditions of the residents.
Failure to Administer Required HIV Medication
Penalty
Summary
The facility failed to ensure that a resident received her required HIV medication, which was a deficiency in providing treatment and care according to professional standards of practice. The resident, who was admitted with a diagnosis of HIV, had discharge instructions from a local rehabilitation center that included an order for Bictegravir/Emtricitabine/Alafenamide to be taken daily. However, a review of the Medication Administration Record (MAR) from June to October revealed no documentation of this medication being administered. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's HIV medication. An LPN stated that the medication was discontinued after a clinic visit, but upon review, there was no order to discontinue it. The Director of Nursing admitted to being unaware of the discharge orders from the rehabilitation center and confirmed that the HIV medication was not reordered. A Nurse Practitioner also confirmed the absence of an order for the medication, and a Clinical Registered Nurse verified that the medication should have been reordered according to the discharge instructions.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that direct care staff had the necessary competencies and skills to meet the behavioral health needs of residents, specifically for a resident diagnosed with Adjustment Disorder who exhibited aggressive and confrontational behaviors. The deficiency was identified through interviews and record reviews, revealing that the staff had not received behavior health training, including Crisis Prevention Interventions (CPI), which is crucial for managing such behaviors. This lack of training was confirmed by multiple staff members, including a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), the Director of Nursing (DON), and the facility administrator. The resident in question was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, and had been confrontational and aggressive with staff, as noted in the psychiatric and nurse practitioner progress notes. Despite being aware of the resident's diagnosis and behavioral issues upon admission, the facility did not provide the necessary training to its direct care staff, which had the potential to affect all 59 residents residing in the facility.
Inaccurate Discharge Status Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's discharge status. A review of the clinical record for a resident revealed that the resident was admitted to the facility and later transferred to a local hospital by ambulance. However, the Discharge Minimum Data Set (MDS) inaccurately indicated that the resident was discharged to home/community. Interviews with the RN responsible for entering MDS assessments and the Director of Nursing confirmed the discrepancy, acknowledging that the MDS was coded inaccurately, as the resident was actually discharged to the hospital.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper disinfection of a glucometer used for blood glucose monitoring. During an observation, an LPN was seen using an incontinence wipe, which lacked disinfectant, to clean the glucometer after checking the blood glucose level of a resident. This action was contrary to the facility's policy, which mandates the use of a registered healthcare disinfectant wipe for cleaning glucometers after each use. The LPN confirmed the use of the incorrect wipe during an interview. Additionally, the Director of Nursing acknowledged that the glucometer should be cleaned with approved disinfecting wipes before and after each resident's use.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to promote and facilitate residents' self-determination and support their choices, impacting three residents. Resident #42, who was cognitively intact, was not allowed by staff to visit Resident #48, despite her frequent visits to his room. On a specific occasion, an LPN instructed Resident #42 to return to her room, and on another occasion, both residents were told to either stay in Resident #48's room or leave the hall. Resident #48, who was mildly cognitively impaired, confirmed that he was instructed by the same LPN to either stay in his room or leave the hall, which was acknowledged by the LPN as inappropriate. Additionally, Resident #52, who was cognitively intact and had specific medical conditions, requested that staff wear gloves during medication administration. This request was not honored by the LPN, resulting in Resident #52 refusing his medication. The facility's policy on resident rights emphasizes the importance of self-determination and respect for resident choices, which was not upheld in these instances. The facility administrator confirmed that residents have the right to visit others, be in the hall, and request staff to wear gloves during medication administration.
Failure to Follow Transfer Protocols Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during transfers, leading to an accident. The resident, who was admitted with conditions including cerebral palsy, muscle weakness, and a history of falling, required assistance for all activities of daily living (ADLs) and was dependent on staff for transfers. The facility's policy mandated that two staff members should assist with mechanical lift transfers to prevent accidents. However, the resident's care plan lacked specific interventions for transfer assistance, and the policy was not followed. On the night of the incident, a CNA attempted to transfer the resident alone using a mechanical lift, despite knowing that two staff members were required. During the transfer, the CNA leaned on the resident's leg, causing pain and eventually leading to a diagnosis of a plateau fracture of the left knee. Interviews with staff confirmed that the CNA was aware of the two-person requirement for mechanical lift transfers, yet proceeded alone, resulting in the resident's injury.
Deficiency in Staff Competency for Resident Transfers
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to safely implement a resident's assessed transfer needs. Specifically, the deficiency involved a resident with cerebral palsy, cognitive communication deficit, muscle weakness, history of falling, and unspecified lack of coordination, who required a two-person assist mechanical lift transfer. Despite this requirement, the care plan lacked documentation specifying the amount of assistance and devices needed for the resident's transfers. On one occasion, a CNA transferred the resident independently using a mechanical lift, while another CNA stood in the doorway observing, despite both being aware of the two-person assist requirement. Interviews with the Director of Nursing and a Clinical Registered Nurse confirmed that all mechanical lift transfers should involve two nursing staff members, and it was deemed unacceptable for one staff member to perform such transfers alone.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the conditions observed in Resident #7's room and the common areas of Hall A and Hall C. Resident #7 was found with a soiled, uncovered mattress on the floor beside his bed, stained with dried tube feeding, and a blanket on the floor with three walnut-sized areas of a yellow, moist substance. Interviews with the Director of Nursing (S2DON) and the Administrator (S1ADM) confirmed that the mattress and blanket were not in an acceptable condition and should have been cleaned and covered appropriately. Additionally, the facility's common areas were not maintained in a clean state. Hall A had a strong urine odor and large brown coffee stains on the floor, while Hall C had long brown streaks and black shoe print stains leading to the smoker's patio. Interviews with housekeeping staff (S13HSK, S14HSK, and S15HSK) revealed that no housekeeping was available between 6:00 p.m. and 6:00 a.m., leaving nursing staff responsible for cleaning spills during these hours. The Administrator (S1ADM) confirmed that it was expected for nursing staff, particularly CNAs, to clean up spills after hours to ensure a safe and homelike environment.
Failure to Implement Physician's Orders for MRIs and Oxygen Administration
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents by not adhering to physician's orders. For one resident, who was admitted with diagnoses including low back pain and fibromyalgia, the facility did not schedule or complete the ordered MRIs for the cervical spine, lumbar spine, and shoulder. Despite the pain management clinic initially being responsible for scheduling, the responsibility was transferred to the facility. The facility was aware of the MRI orders but failed to act due to insurance coverage issues, resulting in the MRIs not being scheduled or completed. For another resident, admitted with acute respiratory failure with hypoxia and chronic systolic congestive heart failure, the facility did not follow the physician's order for oxygen administration. The resident was supposed to receive 4 liters of oxygen via nasal cannula to maintain oxygen saturation at 92% or above. However, the resident was incorrectly placed on 10 liters of oxygen, as documented by an LPN who acted on incorrect information received during a morning report. The discrepancy between the physician's order and the administered oxygen level was confirmed by the Director of Nursing.
Medication Borrowing Between Residents
Penalty
Summary
The facility failed to ensure that the services provided met professional standards of quality by allowing nursing staff to borrow medications from one resident to administer to another. Specifically, Resident #R4, who was admitted with a diagnosis of Human Immunodeficiency Virus Disease, had a physician's order for Biktarvy, a medication crucial for managing his condition. However, the medication was never filled, and instead, doses were borrowed from another resident's supply. This practice was in direct violation of the facility's medication administration policy, which prohibits administering medications ordered for one resident to another unless permitted by state law and approved by the Director of Nursing Services. Interviews with various staff members, including LPNs and the Director of Nursing, revealed a lack of awareness and communication regarding the unavailability of Resident #R4's medication. The pharmacy confirmed that they had not received an order for Biktarvy for Resident #R4, indicating a breakdown in the medication ordering process. Despite the facility's policy requiring verification of medication orders and administration, the staff failed to adhere to these standards, resulting in the inappropriate borrowing of medication between residents.
Failure to Provide Essential Medications to Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in a deficiency. Resident #6, who was cognitively intact and had diagnoses including low back pain and gastroesophageal reflux disease, did not receive her prescribed medications, Nexium and Norco, as they were unavailable. Interviews and observations revealed that the facility had been out of Nexium for two to three days, and at one point, for a month. Norco had not been available for several months. The facility's staff, including the LPN and DON, confirmed the absence of these medications despite active orders. Resident #R4, diagnosed with Human Immunodeficiency Virus Disease, also experienced a lack of pharmaceutical services. The resident had an active order for Biktarvy, a medication crucial for managing his condition, but it was never filled or available in the facility. Interviews with the LPN and the pharmacist confirmed that the pharmacy had not received the order for Biktarvy, and the medication was not present in the medication cart. The facility's policy on pharmaceutical services mandates the accurate acquiring, receiving, dispensing, and administering of medications to meet residents' needs. However, the facility failed to adhere to these procedures, resulting in the unavailability of essential medications for Resident #6 and Resident #R4. The pharmacist and nurse practitioner were unaware of the medication shortages, indicating a breakdown in communication and coordination within the facility's pharmaceutical services.
Infection Control Deficiency Due to Improper PPE Use
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) by staff. Specifically, a Certified Nursing Assistant (CNA) did not wear a gown while changing the soiled incontinent brief of a resident who was on Enhanced Barrier Precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). The facility's policy, dated May 2023, requires the use of gowns and gloves during high-contact resident care activities, such as changing briefs. An observation confirmed that the CNA did not adhere to this policy, and the Director of Nursing (DON) acknowledged the oversight. The resident involved had been admitted with diagnoses of Dysphagia, Oropharyngeal Phase, and Gastrostomy Tube, and had signage indicating the need for a gown during direct care.
Deficient Pest Control Program in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests and insects in various resident rooms. Observations revealed live and dead roaches in multiple rooms, including Resident #6's room, where roaches were seen crawling from under the wheelchair to under the bed. Resident #6 reported seeing roaches daily. In another room, four dead roaches were found inside a toilet paper roll, and Resident #3's bathroom had live roaches between the toilet and baseboard, with the resident confirming daily sightings. Additional observations in other rooms confirmed the presence of roaches and gnats, with staff members acknowledging the widespread issue. Interviews with facility staff and a pest control company representative highlighted the lack of regular pest treatment in all resident rooms. The pest control representative stated that rooms were not treated regularly unless notified of specific pest issues. The facility's administrator confirmed frequent contact with the pest control company but acknowledged that not all rooms had been treated for pests. The Director of Nursing also confirmed the presence of gnats in Resident #9's room, despite unsuccessful attempts to remove them. These findings indicate a deficiency in the facility's pest control measures, affecting the living conditions of 67 residents.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician after a significant change in the resident's physical and mental status. The resident, who had severe cognitive impairment and multiple medical conditions including chronic atrial fibrillation and unspecified dementia, exhibited low blood pressure readings and increased confusion over several days. Despite these changes, there was no documentation that the physician or nurse practitioner was notified, as required by the facility's policy. Interviews with staff revealed that the nurses were aware of the abnormal vital signs and increased confusion but did not notify the physician or document the notification. The Director of Nursing expected nurses to use their judgment for physician notification, but the nurse practitioner confirmed that he was not informed of the resident's low blood pressure and altered mental status. The lack of documentation and communication led to a deficiency in the facility's compliance with its policy on notifying changes in a resident's condition.
Failure to Document Reason for Hospital Transfer
Penalty
Summary
The facility failed to document the reason for a resident's transfer to the hospital in the medical record, which is a requirement according to their policy. The policy mandates that when a resident is transferred or discharged, the reason must be documented in the medical record. In this case, a review of the medical record for a resident who was admitted and later transferred to the hospital revealed no documentation of the reason for the transfer. The facility's Emergency Transfer Log indicated that the resident was transferred for a medical reason and did not return, but the Nurses' Notes lacked any documentation explaining the transfer. During an interview, the Director of Nursing (DON) confirmed that there was no documentation in the medical record to indicate why the resident was sent to the hospital, acknowledging that there should have been such documentation.
Failure to Change Enteral Feeding Bag and Label Opened Solution
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident receiving enteral feeding, leading to deficiencies in care. Resident #7, who was admitted with diagnoses including Dysphagia and Gastrostomy Status, was observed with a tube feeding solution bag that had not been changed for over 24 hours, contrary to the requirement for it to be replaced every 24 hours. Additionally, an opened container of the enteral feeding solution was found in the resident's room without a label indicating the date and time it was opened, which is necessary to ensure the safety and efficacy of the feeding solution. During observations and interviews, it was confirmed by the LPN, DON, and Administrator that the tube feeding bag should have been replaced after 24 hours and the opened container should have been labeled with the date and time it was opened. These oversights were acknowledged by the staff, indicating a lapse in following proper protocols for enteral feeding management, which could potentially lead to complications for the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to accurately document the Medication Administration Record (MAR) for a resident, leading to a deficiency in maintaining medical records according to professional standards. The resident, who was admitted with multiple diagnoses including Diabetes Insipidus, Congestive Heart Failure, and severe cognitive impairment, had several medications and treatments not documented as administered on specific dates. These included Levothyroxine, Diabetasource AC, Humalog Quick Pen, Lantus Solostar insulin, Amantadine HCL, and Eliquis, all of which were not recorded as given on the MAR. Interviews conducted with the nursing staff revealed that the medications were indeed administered but not documented. An LPN confirmed that she administered the medications but failed to update the MAR. The Director of Nursing (DON) also confirmed after reviewing the MAR that the medications were administered but not documented. This lack of documentation constitutes a failure to safeguard resident-identifiable information and maintain accurate medical records, as required by professional standards.
Missed Follow-Up Appointment for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. The resident, who was cognitively intact and had diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Morbid Obesity, was supposed to attend a follow-up appointment at an outpatient wound clinic. The physician's orders specified that the dressing for the diabetic ulcer on the resident's left heel was to be changed by the outpatient wound clinic on Mondays and by the facility on Thursdays and as needed. However, the resident missed the scheduled follow-up appointment on June 24, 2024, as there was no evidence in the nurse's notes that the appointment was attended. Interviews conducted with the resident and facility staff revealed that the appointment was not documented on the facility calendar, leading to the resident missing the follow-up. The staff responsible for scheduling appointments confirmed that the appointment was not recorded, and the LPN stated that the after-visit summary with the appointment details could not be found. The Director of Nursing also acknowledged that the appointment was missed, indicating a lapse in the facility's process for managing and documenting medical appointments for residents with critical care needs.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several observations and interviews. In Room A, there were multiple cleanliness issues, including hair balls, personal hygiene items left in the sink, and hair on the floor. Additionally, the shower area was not properly maintained, with open shampoo bottles on the floor, non-functional control knobs, and a shower head lying on the floor. These conditions were confirmed by the Director of Nursing (DON) to have been left by the weekend staff and not addressed by housekeeping or CNAs as required. In Room B, two ceiling tiles were observed to have large brown stains, which had been present for an extended period according to a resident's report. The DON confirmed that these tiles should have been replaced. Further inspection of Room A revealed a used disposable razor without a safety cover on the floor, which was also confirmed by the DON as inappropriate. The facility administrator acknowledged that Room A should be cleaned daily and that stained ceiling tiles should be replaced, but these actions had not been taken.
Improper Food Storage Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect all residents served from the kitchen. During an initial tour of the kitchen, it was observed that a bulk storage container contained an open bag of sugar with a paper cup inside, and the lid of the container was left open. Additionally, another bulk storage container was found with opened bags of flour and rice, and its lid was also left open. Interviews conducted with staff members confirmed these findings. S4DM acknowledged that the bulk storage containers should be securely closed and should not contain a paper cup. Similarly, S1ADM confirmed the same expectations for the storage containers.
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What surveyors actually found near you
We read the 125 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
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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) |
|---|---|---|---|---|
| The Woodleigh Of Baton Rouge | 0.3 mi | ★★★★★ | 1 | 0 |
| Flannery Oaks Guest House | 1.1 mi | ★★★★★ | 0 | 0 |
| Capitol House Nursing And Rehab Center | 2 mi | ★★★★★ | 0 | 0 |
| White Oak Post Acute Care | 2.7 mi | — | 12 | 1 |
| The Guest House Care Center | 2.9 mi | ★★★★★ | 0 | 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.