Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Clare Manor Nursing And Rehabilitation during CMS and state inspections, most recent first.
Loose, unlabeled pills were found in a resident room and in two med carts during observations. An LPN confirmed an unlabeled broken pill was on the floor of a resident room, and two LPNs confirmed loose, unlabeled pills were in the drawers of two med carts. The DON later confirmed medications should not be loose and unlabeled in med carts or on the floor of a resident room.
Failure to provide ordered nutritional supplement with meals. A resident with malignant neoplasm of the brain, colostomy status, and moderate cognitive impairment had a provider order for Mighty Shakes or equivalent with each meal due to potential weight loss/gain and altered nutrition related to the facility ordered diet. Observations of breakfast trays on separate days showed no supplement present, and a CNA confirmed the tray did not include it. The ADON later confirmed the resident should have received the supplement with all meals.
Failure to honor a resident’s food preference. A cognitively intact resident had a documented dislike for red beans and rice, and the dietary system generated entree and starch substitutions; however, an observation showed the resident was served red beans and rice anyway. The RD confirmed the resident should have received the alternate meal, and the DON stated residents should receive meals according to their preferences.
Failure to communicate oxygen changes to hospice staff. A resident on hospice had standing O2 orders for 2-5 L via NC PRN, but was observed receiving 6 L via NC. An LPN said she did not know the resident’s current O2 rate, and the hospice nurse confirmed the facility did not notify hospice of the increase. The DON confirmed the nurse should have informed hospice when the resident required 6 L for comfort.
A resident with mild protein-calorie malnutrition and hypokalemia did not receive the correct double portions diet as ordered. The facility's policy required nursing staff to verify the correct diet before serving, but an observation revealed the resident's lunch tray contained only single portions. Interviews with an LPN and the Dietary Manager confirmed the discrepancy, and the administrator acknowledged the failure to provide the ordered double portions.
A resident with lactose intolerance was served whole milk instead of lactose-free milk, contrary to her care plan and meal ticket instructions. The error was confirmed by staff, highlighting a failure in the facility's dietary service procedures.
A resident's MAR was inaccurately documented, failing to reflect the timely administration of a Fentanyl patch as per physician orders. An LPN documented the patch change before it was applied, leading to a lapse in medication administration. The DON confirmed the documentation was inaccurate and not in line with professional standards.
A resident's medical records were inaccurately maintained when Ativan was prescribed for Anxiety but recorded for Dementia with Behavioral Disturbance. The error persisted in the Medication Administration Record, and interviews confirmed the discrepancy. The DON acknowledged the expectation for accurate transcription of orders.
A facility failed to adhere to its infection control program by not changing a resident's PICC line dressing as required. Despite physician orders and facility policy mandating weekly changes, the dressing was not changed for over a week, as confirmed by staff interviews and record reviews. This oversight was acknowledged by the RNs and the DON, highlighting a deficiency in infection control practices.
A resident with severe cognitive impairment was found with a fractured leg, but the injury was not reported to the State agency within the required 2-hour timeframe. Staff were aware of the injury but failed to notify the Administrator or the State agency promptly, leading to a delay in reporting.
Loose, Unlabeled Pills Found in Resident Room and Medication Carts
Penalty
Summary
Drugs and biologicals were not stored in accordance with currently accepted professional principles because loose, unlabeled pills were found in a resident room and in medication carts. During medication administration in a resident's room, an unlabeled, oblong white pill broken in half was observed on the floor. The LPN present confirmed the pill was on the floor and should not have been there. Two medication carts were also found to contain loose, unlabeled pills. One cart had five loose, unlabeled pills in the bottom of the drawers, and another cart had one half of a white pill, loose and unlabeled, in the bottom of a drawer. The LPNs present confirmed the pills were loose and unlabeled and should not have been in the carts. The DON was later informed and confirmed medications should not be loose and unlabeled in medication carts or on the floor of a resident's room.
Failure to Provide Ordered Nutritional Supplement With Meals
Penalty
Summary
The facility failed to ensure a resident was offered a therapeutic diet when the health care provider ordered a nutritional supplement. Resident #95 was admitted with diagnoses including malignant neoplasm of the brain and colostomy status, and his quarterly MDS showed a BIMS of 9, indicating moderate cognitive impairment. His physician orders included Mighty Shakes with meals and a house supplement or equivalent with each meal, starting 09/12/2025, for potential weight loss/gain and altered nutrition related to the facility ordered diet. On 05/05/2026, an observation of the resident’s breakfast tray at bedside showed no Mighty Shake or equivalent. On 05/06/2026, another observation of the resident’s breakfast tray being delivered by a CNA again showed no Mighty Shake, and the CNA confirmed the tray did not include one. Later that day, the ADON reviewed the orders and confirmed the resident should have a Mighty Shake or equivalent on his tray with all meals.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to provide food that accommodated a resident’s stated food preference for 1 of 9 residents reviewed for food accommodations and preferences. Resident #9 was readmitted to the facility and had a Quarterly MDS with a BIMS of 14, indicating he was cognitively intact. The May 2026 menu listed red beans with rice as the entree and starch, with a substitute alternative available, and the dietary system documented that Resident #9 disliked red beans and rice. However, on 05/04/2026 at 12:30 p.m., an observation and interview showed red beans and rice on Resident #9’s tray, and the resident stated he did not like red beans and rice. Review of the lunch dietary ticket for that meal showed entree substitute and starch substitute. The RD confirmed the ticket indicated substitutions and stated Resident #9 should not have been served red beans and rice but should have received the alternate meal. The DON also confirmed residents should receive meals according to their preferences.
Failure to Communicate Oxygen Changes to Hospice
Penalty
Summary
The facility failed to communicate with hospice staff regarding a resident’s current oxygen orders. Resident #144 was admitted to the facility and later admitted to hospice services on 04/29/2026. The facility’s hospice policy stated that the facility was responsible for coordinating with the hospice representative and communicating, with documentation, to ensure the resident’s needs were addressed and met 24 hours per day. Review of the hospice binder showed standing orders for oxygen at 2-5 liters via nasal cannula as needed. On 05/04/2026, the resident was observed supine in bed receiving oxygen at 6 liters per minute via nasal cannula. An LPN stated she did not know the resident’s current oxygen rate and only needed to check it once on her shift. The hospice nurse confirmed the resident had been receiving oxygen at 2 liters via nasal cannula, had been observed at 4 liters during a hospice visit, and that the facility did not communicate that the oxygen had been increased to 6 liters via nasal cannula. The DON confirmed the hospice orders included oxygen at 2-5 liters via nasal cannula and that the facility nurse should have notified hospice when the resident required 6 liters for comfort.
Failure to Provide Correct Portion Sizes for Resident
Penalty
Summary
The facility failed to ensure that menus were followed to meet the nutritional needs of residents, specifically by not providing the correct portion sizes as ordered for a resident. The facility's policy required nursing staff to check each food tray for the correct diet before serving residents. However, during an observation, it was noted that a resident with a diagnosis of mild protein-calorie malnutrition and hypokalemia, who had a physician's order for a double portions diet, did not receive the correct portion sizes on their lunch tray. The resident's lunch tray was observed to contain only single portions of various food items, despite the tray ticket indicating a requirement for double portions. Interviews with the LPN and the Dietary Manager confirmed that the lunch tray did not meet the ordered double portions. The facility administrator also acknowledged that the resident should have received double portions at every meal, indicating a failure to adhere to the dietary orders and facility policy.
Failure to Accommodate Dietary Needs for Lactose Intolerant Resident
Penalty
Summary
The facility failed to provide a resident with meals that accommodated her lactose intolerance, as required by her care plan. Resident #5, who is lactose intolerant, was observed being served whole milk instead of lactose-free milk during breakfast. This was despite her meal ticket clearly indicating that she should receive lactose-free milk. The error was confirmed by S9CNA, who was feeding the resident, and later by S4ADON and S3ADM, who reviewed the meal ticket and acknowledged the mistake. This oversight occurred despite the facility's policy requiring both the food service manager or supervisor and nursing staff to check trays for correct diets before serving residents.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's Medication Administration Record (MAR) for pharmaceutical services. Specifically, the deficiency involved Resident #2, who had a physician's order for a Fentanyl Transdermal Patch to be applied every three days for pain management. On February 19, 2025, an observation revealed that the Fentanyl patch on Resident #2's right chest wall was dated February 16, 2025, indicating it had not been changed as per the physician's order. The MAR inaccurately documented that the patch was removed and a new one applied on February 19, 2025, at 6:00 a.m., signed by S8LPN. During an interview, S8LPN admitted to documenting the administration of the Fentanyl patch before actually applying it, due to being distracted by another situation. This resulted in the patch not being changed as required. The Director of Nursing (S2DON) confirmed that all medications should be administered according to physician orders and that the documentation should be accurate. The inaccurate documentation of the Fentanyl patch administration for Resident #2 was acknowledged as a failure to adhere to the facility's policy and professional standards.
Inaccurate Transcription of Medication Diagnosis
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to a deficiency. The resident was admitted with diagnoses including Dementia with Behavioral Disturbance, Psychotic Disturbance, and Anxiety. A telephone order was made to start Ativan for the resident, with the diagnosis inaccurately transcribed as Dementia with Behavioral Disturbance instead of Anxiety. This error was reflected in the resident's Medication Administration Record for May and June 2024, where Ativan was administered for Dementia with Behavioral Disturbance. Interviews with the prescribing nurse practitioner and a psychiatrist confirmed that Ativan was intended to treat Anxiety, not Dementia, and that Dementia was not an appropriate diagnosis for Ativan. The Director of Nursing acknowledged the expectation for accurate transcription of physician telephone orders in the resident's clinical record.
Inadequate PICC Line Dressing Management
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper management of a PICC line dressing for a resident. The facility's policy required that PICC line dressings be changed every seven days or as needed if the dressing became damp, loosened, or visibly soiled. However, the facility did not adhere to this policy for a resident who was readmitted with a diagnosis of sepsis. The resident's clinical records and treatment administration records showed no documented evidence of the PICC line dressing being changed from the time of readmission until the survey date, despite physician orders specifying weekly changes and as needed. Observations and interviews with nursing staff confirmed that the PICC line dressing, dated from the time of the resident's hospital discharge, had not been changed as required. Both the RNs and the Director of Nursing acknowledged the oversight and confirmed the lack of documentation indicating that the dressing had been changed. This failure to follow established protocols and physician orders resulted in a deficiency in the facility's infection control practices, potentially compromising the resident's health and safety.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an injury of unknown origin was reported immediately, but not later than 2 hours after the incident, to the facility Administrator and to the State Survey Agency within the specified timeframe. Resident #1, who was severely cognitively impaired with a BIMS of 00, was found with swelling and edema in her left lower leg on 04/19/2024. An x-ray revealed an acute fracture of the distal tibia and proximal fibula, and the resident was subsequently transferred to a local hospital. However, the injury was not reported to the State agency within the required 2-hour window. Interviews with staff revealed that the injury was discovered by a CNA and assessed by an LPN, who then contacted the on-call Nurse Practitioner and ordered an x-ray. The x-ray results, which confirmed the fracture, were received later that evening, but the injury was not reported to the State agency until the following morning. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were aware of the injury but did not notify the Administrator or the State agency in a timely manner. The Administrator was only informed of the injury the next morning, and the report to the State agency was filed at 9:43 a.m. on 04/20/2024, well beyond the 2-hour reporting requirement. The delay in reporting the injury of unknown origin constitutes a failure to comply with the facility's policy and state regulations, which mandate immediate reporting of such incidents to ensure timely investigation and intervention.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baton Rouge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baton Rouge General Medical Center, Snf | 1.9 mi | ★★★★★ | 1 | 0 |
| Capital Oaks Nursing & Rehabilitation Center Llc | 2.2 mi | ★★★★★ | 1 | 0 |
| Mid City Community Nursing And Rehab | 2.2 mi | ★★★★★ | 5 | 0 |
| Sterling Place Healthcare & Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| The Guest House Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.