Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Guest House Care Center during CMS and state inspections, most recent first.
Failure to Protect Residents from Abuse by an Aggressive Resident A cognitively impaired resident with agitation and behavioral disturbance repeatedly assaulted and intimidated other residents in the courtyard. He poured coffee on one resident in a wheelchair, hit another resident and took his hat and sunglasses, and later knocked a hat off a third resident, scratched his face, pushed him out of his wheelchair, and fought with another resident. Staff interviews described the behavior as bullying and abusive, but leadership repeatedly said it was not abuse because they believed there was no willful intent.
A resident with Cerebral Infarction and Dysphagia had an order for a pureed texture with nectar/mildly thick consistency, but lunch observations showed the puree meal was lumpy, sticky, grainy, and stringy with visible stems. A kitchen puree trial tray showed the same inconsistent texture, and staff confirmed puree solids should be smooth throughout; the DON stated 10 residents consumed puree food from the kitchen.
A resident’s bathroom ceiling was observed on two occasions with a splotchy gray substance covering much of the surface. Maintenance records showed no work order for the issue, and the maintenance staff member said he had not noticed it while fixing the toilet and did not do proactive room rounds unless notified. The ADM confirmed he was unaware of the substance and agreed it should not have been on the ceiling.
Failure to report abuse allegations to the State Survey Agency: A resident was involved in a courtyard altercation where coffee was thrown and open-fist striking occurred, and two other residents were later involved in a separate fight where one resident was knocked from a wheelchair, pushed to the ground, and struck while staff intervened. The ADM stated he did not report the incidents because he did not consider one event abuse and did not know he needed to report the other.
A resident with Alzheimer's Disease, CVA, dysphagia, and PEG tube feeding orders was supposed to be NPO, but an unsealed bottle of mouthwash was observed within her reach at bedside. Staff, including an LPN and the DON, confirmed the resident was NPO and that the mouthwash should not have been accessible because it was a liquid she could ingest.
Failure to provide appropriate pressure ulcer care occurred when a resident with Parkinson's disease and a Stage IV sacral PU was not repositioned every 2 hours as ordered. The resident's care plan and physician orders required q2h turning/repositioning, but staff observed the resident remained on the same side for hours after wound care. An RN confirmed the resident was high risk for skin impairment, and an AB stated she only repositioned the resident about every 3 hours due to other duties.
The facility failed to implement comprehensive care plans for two residents. One resident, with multiple diagnoses including dementia and a fractured femur, did not have wheelchair brake extenders as ordered by a physician. Another resident, dependent on assistance for ADLs, lacked a care plan addressing these needs. Staff confirmed these oversights, indicating a failure to follow physician's orders and properly plan for resident care.
A resident with a history of falls and multiple diagnoses, including a fractured femur and dementia, experienced an unwitnessed fall in the lounge area. The facility failed to update the resident's care plan with new fall interventions after the incident, as confirmed by the MDS nurse and DON, who acknowledged the oversight in care plan revision responsibilities.
A resident with chronic pain was prescribed Oxycodone, but an LPN failed to document its administration in the MAR at the time it was given. The LPN admitted to delaying documentation until later in the shift, leading to multiple instances of late entries over two months. The DON confirmed that immediate documentation was expected but not followed.
A resident experienced a significant change in condition, including pain and inability to ambulate, which was not reported to the on-call medical provider as required. This delay led to a diagnosis of a femur fracture and necessitated a hospital transfer for surgery. Interviews with staff confirmed the oversight in communication.
A resident in a long-term care facility experienced a significant change in condition, including new onset pain, swelling, and inability to bear weight, which was not adequately recognized, monitored, or documented by the nursing staff. Despite the resident's severe cognitive impairment and baseline of independent ambulation, the staff failed to notify the medical provider or document the changes, leading to a delay in treatment. The resident was later diagnosed with a femur fracture, requiring hospitalization and surgery.
A resident with a documented Do Not Resuscitate (DNR) order was found unresponsive with a belt around their neck. An LPN initiated CPR without checking the resident's code status, contrary to the facility's policy. The Director of Nursing confirmed the lapse in procedure, highlighting a failure to respect the resident's advance directive.
The facility failed to maintain accurate medical records for a resident with Major Depressive Disorder. An LPN documented sadness on the MAR due to system limitations, despite the resident not displaying such symptoms. The DON confirmed the inaccuracies.
The facility failed to provide timely incontinence care for two residents, leaving them in soiled conditions for an extended period. Both residents were found with saturated incontinence briefs, pads, and sheets, and one had stool on her buttocks. The assigned CNA did not perform the required care during her shift and did not seek assistance.
The facility failed to assess a resident for the risk of entrapment from bedrails and did not obtain informed consent prior to their installation. The resident had multiple diagnoses and required side rails for bed mobility, but there was no documentation of an entrapment risk assessment or consent from the resident's representative.
The facility failed to ensure that CNAs demonstrated competency in necessary skills and techniques, leading to inadequate care for two residents. One resident was not transferred out of bed as needed, and another received an inexperienced bed bath. The CNA's orientation was signed off without proper competency checks, and the CNA lacked computer access to review care plans.
The facility failed to ensure that a newly hired CNA was competent in assisting residents with ADLs, leading to inadequate care for two residents. The CNA did not receive proper training or supervision, and her competency was signed off without verification.
A resident with moderate cognitive impairment and requiring extensive assistance with transfers was not assisted out of bed at her requested time of 10:00 a.m. Staff were aware of her preference but failed to provide the necessary assistance, leaving the resident in bed until her family member arrived to help.
The facility failed to ensure residents received mail on Saturdays, affecting four residents. Staff responsible for mail distribution only worked Monday through Friday, resulting in weekend mail being held until Monday.
The facility failed to resolve a grievance regarding a missing phone charger for a resident with severe cognitive impairment. The issue was reported to a CNA and an LPN, but neither escalated it to the administration, resulting in the grievance not being documented or resolved as required by the facility's policy.
Failure to Protect Residents from Abuse by an Aggressive Resident
Penalty
Summary
The facility failed to protect residents from physical and mental abuse by a resident with cognitive impairment and a history of agitation and behavioral disturbance. Resident #86 had diagnoses including Alzheimer’s disease, psychotic disorder, mild neurocognitive disorder with behavioral disturbance, restlessness and agitation, cognitive communication deficit, and anxiety disorder. The resident’s quarterly MDS indicated a BIMS of 9 and that he was ambulatory without assistance. Facility records and interviews described repeated aggressive interactions in the courtyard involving Resident #86 and multiple other residents. On 04/12/2026, Resident #86 poured coffee toward Resident #63 in the courtyard, and staff later reviewed video showing the beverage being thrown in Resident #63’s direction. Resident #63 reported that Resident #86 stood over him in his wheelchair, threw coffee on him, and slapped him. Facility staff and leadership described the event as not abuse because they believed there was no willful intent and no injury. Resident #63 had a BIMS of 8 and was non-ambulatory, requiring a wheelchair for mobility. On 05/05/2026, Resident #86 was involved in another altercation in the courtyard with Resident #46. Nursing notes and interviews stated Resident #86 hit Resident #46 in the back of the head or with a closed fist, took Resident #46’s hat and sunglasses, and would not return the items. Resident #46 had diagnoses including vascular dementia, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, and a personal history of adult psychological abuse. Staff interviews described Resident #46 as childlike, scared of Resident #86, and more vulnerable to psychological abuse, yet leadership stated the behavior was not abuse because they believed there was no willful intent. On 05/07/2026, Resident #86 again became aggressive in the courtyard, knocking Resident #61’s hat off, scratching Resident #61’s face, pushing Resident #61 out of his wheelchair onto the ground, and engaging in fighting with Resident #19. Resident #61 had a BIMS of 12 and required a wheelchair for mobility. Resident #19 reported that Resident #86 slapped Resident #61, punched him, and continued the aggression after staff separated the residents. Staff interviews confirmed that Resident #86 had a pattern of knocking hats off residents, taking personal items, calling Resident #46 names, and bullying residents, and that the resident was not always supervised when these events occurred.
Puree Diet Not Prepared to Ordered Consistency
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including Cerebral Infarction and Dysphagia received puree food prepared in a form designed to meet her individual needs. The resident had a physician order for a pureed texture with nectar/mildly thick consistency, and her care plan directed staff to provide and serve the diet as ordered. During lunch observation, the resident’s pureed meal was noted to be inconsistent with a smooth puree: the red beans had small lumps throughout, the white rice appeared sticky and grainy, and the greens were stringy with stems still visible. A separate observation of a puree trial tray from the kitchen showed the same issues with the pureed solids. Staff interviews confirmed that puree solids should be smooth throughout and should not be sticky, grainy, lumpy, or stringy, and the DON stated that 10 residents consumed puree food from the facility’s kitchen.
Unaddressed Substance on Resident Bathroom Ceiling
Penalty
Summary
The facility failed to ensure Resident #72 had a clean and homelike bathroom environment when the resident’s bathroom ceiling was observed on two separate occasions to have a splotchy gray-colored substance covering approximately two-thirds of the ceiling. A review of the maintenance log for the prior three months showed no evidence that the bathroom ceiling had been reported for maintenance. During interview, S15MS confirmed he had been in the resident’s bathroom fixing the toilet on both occasions and had not noticed the ceiling, stated staff had not submitted a work order for it, and acknowledged he did not complete proactive rounds unless staff notified him of an issue. S15MS also stated the substance appeared to be mold or mildew and should not have been on the bathroom ceiling. S1ADM later confirmed he was unaware of the substance and agreed the bathroom ceiling should not contain it.
Failure to Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of mental and physical abuse to the State Survey Agency immediately, and no later than 2 hours, for 3 of 5 residents reviewed for abuse. The facility policy stated that any employee who becomes aware of abuse must immediately report it to the administrator, and the administrator must immediately initiate a report to the state agency, but not less than 2 hours after forming the suspicion of a crime if the allegation involves physical, verbal, or mental abuse. For one incident, Resident #63 reported that on 04/12/2026 Resident #86 stood over him in his wheelchair, threw coffee on him, and slapped him with an open fist in the courtyard. S13NP stated she was told that Resident #63 and Resident #86 were outside when Resident #86 poured coffee on Resident #63 and both residents started swinging open fist at each other. The facility’s State Agency Reported Incidents review showed no report for this altercation, and S1ADM stated he did not report it because he believed there was no willful action or ill intent and did not consider it abuse. For another incident, Residents #19 and #61 reported that on 05/07/2026 Resident #86 knocked off Resident #61’s hat, swung at him, pushed him out of his wheelchair, and continued swinging closed fists while Resident #61 was on the ground; Resident #19 also stated he punched and kicked Resident #86 during the altercation. S5CNA and S2DON described the same courtyard fight and confirmed Resident #86 was separated, returned to his room, then came back outside and continued the altercation. Resident #61 reported scratches and a facial laceration, and S1ADM acknowledged he did not report the incident to the state agency because he did not know he needed to.
NPO Resident Had Accessible Mouthwash
Penalty
Summary
The facility failed to ensure interventions for dysphagia were implemented as identified on the care plan and in physician orders for a resident with diagnoses including Alzheimer's Disease, Cerebral Infarction, Dysphagia, and gastrostomy status. The resident's quarterly MDS showed a BIMS of 8, indicating moderately impaired cognition. Her physician orders included NPO status related to dysphagia following cerebral infarction, and her care plan stated that she required tube feeding via PEG and was NPO, with tube feeding assistance to be provided per MD orders. During observations, an unsealed bottle of mouthwash was found on the resident's bedside table within her reach while she was in her room. Staff interviews confirmed the resident was on an NPO diet and that mouthwash should not have been accessible to her because it was a liquid she could ingest. The DON also confirmed that the resident should not have had mouthwash accessible and within her reach in her room.
Failure to Reposition Resident With Pressure Ulcers Every 2 Hours
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for Resident #22, who was admitted with Parkinson's disease and pressure-related wounds and later developed a Stage IV sacral pressure ulcer. The resident's record showed a care plan and physician order for turning and repositioning every 2 hours or as appropriate, and the facility's skin protocol also directed residents to be turned/repositioned every 2 hours or as appropriate. A quarterly MDS indicated the resident was cognitively intact but required substantial to maximal assistance to roll from side to side. During observation on 06/02/2026, staff repositioned the resident after wound care at 10:15 a.m., but the resident remained on her left side with a wedge under her right side for several hours afterward. An RN confirmed the resident had not been repositioned again until 1:37 p.m. and stated the resident was high risk for skin impairment, had poor nutrition, and that failure to turn and reposition could worsen the pressure ulcers. An AB stated she only turned or repositioned the resident at minimum every 3 hours because of other duties, and the ADON confirmed staff were expected to turn and reposition residents every 2 hours, especially this resident with skin impairment.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #2, who was admitted with diagnoses including muscle weakness, dementia, Alzheimer's disease, repeated falls, and a fracture to the right femur, had a physician's order for wheelchair brake extenders for safety. However, during an observation, it was noted that the brake extenders were not in place, and the Assistant Director of Nursing (S2ADON) confirmed this oversight. The Director of Nursing (S1DON) also acknowledged that staff were expected to follow physician's orders, which was not done in this case. Resident #3, admitted with diagnoses including a fractured right femur, dementia, pain, and insomnia, was found to be dependent on assistance for activities of daily living (ADLs) such as eating, oral hygiene, toileting, showering, dressing, and personal hygiene. Despite these needs, the resident's care plan lacked interventions for ADLs dependency deficits. The MDS Coordinator (S3MDS) confirmed that these deficits should have been addressed in the care plan, and the Director of Nursing (S1DON) also verified that the resident was not properly care planned for these needs.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise a resident's care plan to include updated fall interventions after a fall incident. Resident #3, who was admitted with diagnoses including a fractured right femur, dementia, pain, and insomnia, experienced an unwitnessed fall in the common lounge area on 12/31/2024. The resident was found sitting half on the wheelchair footrest with her right leg hanging over it, having slid out of the wheelchair. Despite this incident, the resident's care plan was not updated to include new interventions to prevent future falls. Interviews with facility staff revealed that the Minimum Data Set (MDS) nurse was responsible for updating care plans following incidents such as falls. Both the MDS nurse and the Director of Nursing (DON) confirmed that the care plan should have been revised to include interventions after the fall on 12/31/2024, but it was not. This oversight indicates a failure in the facility's process for ensuring timely updates to care plans following significant events affecting resident safety.
Failure to Document Timely Administration of Pain Medication
Penalty
Summary
The facility failed to ensure that services were provided to meet professional standards of quality in the administration of pain medication for one of the residents reviewed. Specifically, the facility did not document the administration of Oxycodone in the Medication Administration Record (MAR) at the time of administration for a resident who was prescribed Oxycodone 10 mg four times daily for chronic pain. The resident had a medical history that included chronic pain, opioid use, peripheral vascular disease, and an acquired absence of the right leg above the knee. The Licensed Practical Nurse (LPN) responsible for administering the medication admitted to not documenting the administration of Oxycodone at the time it was given. Instead, the LPN would wait until later in the shift to enter all documentation, resulting in multiple instances of delayed documentation over a two-month period. The Director of Nursing (DON) confirmed that the expectation was for nurses to document medication administration immediately after it was completed, which was not adhered to in this case.
Failure to Report Significant Change in Condition
Penalty
Summary
The facility failed to ensure timely communication of a significant change in condition to a resident's physician, resulting in an Immediate Jeopardy situation. A resident, who was typically active and able to ambulate independently, experienced a significant change in condition on the morning of July 13, 2024. The resident complained of pain in the lower extremities, exhibited swelling in the left knee, and was unable to bear weight or ambulate. Despite these symptoms indicating a significant change in condition, the on-call medical provider was not notified immediately by the nursing staff. The resident's condition continued to decline over the following days, with no further documentation or notification to the medical provider until July 15, 2024. On this date, an x-ray was ordered, revealing an acute left proximal femur fracture and chondral irregularity of the left femoral head, which could indicate avascular necrosis (AVN). The delay in notification and subsequent medical intervention resulted in the resident being transferred to the hospital for a Left Hip Hemiarthroplasty on July 16, 2024. Interviews with facility staff confirmed that the resident's significant change in condition was recognized but not reported to the medical provider as required by the facility's policy. The LPNs and the Assistant Director of Nursing acknowledged the oversight and confirmed that the on-call nurse practitioner should have been notified immediately. The delay in reporting led to a decline in the resident's range of motion, mobility, and prolonged pain.
Failure to Recognize and Address Resident's Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice for a resident who experienced a significant change in condition. The resident, who was severely cognitively impaired, was observed to have new onset pain in the lower extremities, swelling in the left knee, and was unable to bear weight or ambulate. Despite these symptoms, the nursing staff did not recognize, monitor, intervene, or document the resident's condition adequately, leading to a delay in treatment. The resident's medical records indicated that prior to the incident, the resident was ambulatory without assistance or pain and was continent. However, from the morning of the incident, the resident exhibited signs of pain, decreased mobility, and new onset incontinence. The nursing staff, including LPNs and CNAs, observed these changes but failed to notify the medical provider or document the resident's condition changes in a timely manner. The resident was eventually diagnosed with an acute left proximal femur fracture after an x-ray was ordered two days later, resulting in hospitalization and surgery. Interviews with the nursing staff revealed a lack of communication and documentation regarding the resident's condition. The staff assumed the resident's symptoms were related to a gout flare-up, which was not previously documented, and did not take appropriate action to address the significant change in condition. The delay in notifying the medical provider and the lack of documentation contributed to the resident's prolonged pain and decline in mobility.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's advance directive, specifically a Do Not Resuscitate (DNR) order. The resident, who had a documented DNR status in their clinical record and care plan, was found unresponsive with a belt around their neck. Despite the clear documentation of the resident's wishes, the Licensed Practical Nurse (LPN) who discovered the resident initiated Cardiopulmonary Resuscitation (CPR) without first checking the resident's code status. This action was contrary to the facility's policy, which requires staff to verify the resident's advance medical directive before initiating CPR. The Director of Nursing (DON) confirmed that the LPN did not follow the proper procedure, which mandates checking the chart for code status before performing CPR. The LPN admitted to panicking upon finding the resident unresponsive and starting CPR without verifying the DNR order. This failure to adhere to the resident's advance directive represents a significant deficiency in the facility's compliance with respecting residents' rights to refuse treatment.
Inaccurate Documentation of Medication Administration Record
Penalty
Summary
The facility failed to maintain accurately documented medical records in accordance with accepted professional standards and practices for one resident. Specifically, the nursing staff inaccurately documented the Medication Administration Record (MAR) for a resident diagnosed with Major Depressive Disorder. The MAR indicated that the resident exhibited sadness on multiple dates, signed by the same LPN. However, during an interview, the LPN admitted that the resident never displayed signs of sadness or depression and that she documented sadness because the electronic system did not allow her to select any other option. The Director of Nursing confirmed the inaccurate documentation upon review.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene. Specifically, the facility did not provide timely incontinence care for two residents, Resident #75 and Resident #88. Resident #75, who had severe cognitive impairment and was always incontinent of bowel and bladder, was observed with a strong urine odor in her room and was found with a saturated incontinence brief, incontinence pad, and fitted sheet, along with stool on her buttocks. Similarly, Resident #88, who had intact cognition but required assistance with ADLs and was at high risk for skin breakdown, was also found with a strong urine odor in her room and a saturated incontinence brief, incontinence pad, and top sheet. Both residents had not received incontinence care during the shift as required by their care plans, which specified care every two hours and as needed. Interviews with the CNA assigned to these residents revealed that she had not provided incontinence care to either resident during her shift and had not reported her inability to complete her duties or asked for assistance. Further interviews with other staff members and the Director of Nursing confirmed that the lack of timely incontinence care was unacceptable and that incontinence rounds should have been performed every two hours. The failure to provide timely incontinence care resulted in both residents being left in soiled conditions for an extended period, which was confirmed by multiple observations and staff interviews.
Failure to Assess Entrapment Risk and Obtain Consent for Bedrails
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bedrails and did not obtain informed consent for bedrails prior to their installation. Specifically, Resident #41, who had multiple diagnoses including movement disorders, dementia, and muscle weakness, was found to have quarter side rails in use without any documented entrapment risk assessment or consent from the resident's representative. The resident's clinical record showed physician orders for the use of side rails for bed mobility and repositioning, but there was no documentation of an entrapment risk assessment or consent for the use of these side rails. Observations and interviews confirmed that the side rails were in use whenever the resident was in bed. Staff interviews revealed that while the side rails were assessed for proper function, no assessment for entrapment risk was conducted. Additionally, the Director of Nursing was unable to provide any documentation indicating that the resident's representative had given consent for the use of the side rails. This lack of documentation and assessment led to the deficiency identified in the report.
Inadequate CNA Training and Competency Checks
Penalty
Summary
The facility failed to ensure that each nurse aide demonstrated competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. Specifically, two residents were affected by this deficiency. Resident #28, who has moderate cognitive impairment and requires extensive assistance with transfers, was not transferred out of bed as needed. The CNA assigned to her was unsure of the resident's transfer status and did not seek assistance from another staff member, despite being unable to perform the transfer alone. This resulted in the resident remaining in bed and feeling that the CNA was incompetent to assist with her transfer needs. Resident #34, who is cognitively intact and requires partial/moderate assistance with bathing, reported that the CNA assigned to her was inexperienced and asked for guidance on how to perform a bed bath. The CNA, who had only been working at the facility for a few days, had not received proper training or computer access to review the residents' care plans. The CNA's orientation was signed off as complete without a return demonstration of care tasks, leading to inadequate care being provided to the resident. Interviews with staff revealed that the CNA's orientation and competency checks were not thoroughly conducted. The CNA responsible for training and signing off on the orientation did not observe the new CNA performing care tasks to ensure competency. Additionally, the Director of Nursing and the Administrator confirmed that the CNA should not have been providing care without knowing the specific assistance each resident required. This lack of proper training and oversight resulted in the CNA being unprepared to meet the residents' needs effectively.
Failure to Ensure CNA Competency in Resident Care
Penalty
Summary
The facility failed to ensure that its resources were used effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being for its residents. Specifically, the facility did not have an effective system in place to ensure that a newly hired CNA was competent in the necessary skills and techniques for assisting residents with activities of daily living (ADLs). This deficiency was identified through interviews and record reviews involving two residents who required assistance with ADLs. One resident, who had diagnoses including hemiplegia and generalized muscle weakness, required assistance with transfers and needed to be transferred on her strong side. The CNA admitted that she was unable to transfer the resident out of bed by herself and did not seek additional help, despite the resident's request. The CNA also stated that she was unsure how to identify a resident's transfer status or the level of assistance required for ADLs. Another resident, who had diagnoses including a fracture of the neck of the femur and morbid obesity, required extensive assistance with ADLs and preferred bed baths. The CNA, who had not received computer login or training on the facility's system, provided a bed bath to the resident without prior demonstration or supervision. The CNA's competency was signed off by a supervisor without proper observation or verification. The Director of Nursing and the Administrator confirmed that the CNA should not have provided care without knowing the specific assistance each resident required and that the supervisor should have ensured the CNA's competency before allowing her to work independently.
Failure to Support Resident's Choice for Transfer Time
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not supporting Resident #28's choice of when to get out of bed. Resident #28, who has moderate cognitive impairment and requires extensive assistance with transfers, expressed a preference to be out of bed by 10:00 a.m. On the day of the incident, Resident #28 requested assistance from S5CNA to be transferred to her wheelchair at 10:00 a.m., but this assistance was not provided. S5CNA informed S4LPN that she could not assist Resident #28 independently, and S4LPN instructed her to get another CNA for help. However, this did not happen, and Resident #28 remained in bed until her family member arrived and transferred her to the wheelchair. Interviews with staff members confirmed that Resident #28's request to be out of bed by 10:00 a.m. was known and should have been honored. S4LPN and S3CNAS both acknowledged that Resident #28 should have been assisted out of bed when she requested. The Director of Nursing (S2DON) also confirmed that Resident #28 should have been transferred out of bed by staff and should not have had to wait for her family member to arrive. This failure to assist Resident #28 in a timely manner demonstrates a lack of support for the resident's right to self-determination and choice.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays, affecting four residents (#6, #51, #53, and #66) out of 17 reviewed during a resident council meeting. The facility's General Admission & Financial Agreement states that residents have the right to promptly receive unopened mail. However, interviews with staff members S5AD and S4FIN revealed that mail delivered on weekends was held until the following Monday due to the absence of staff responsible for mail distribution on Saturdays. Both staff members confirmed that they only worked Monday through Friday, leading to a delay in mail delivery for residents over the weekend.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to initiate and resolve grievances for a resident with severe cognitive impairment. The grievance policy requires that grievances be documented and resolved promptly, but this was not followed in the case of a missing phone charger reported by the resident's responsible party (RP). The RP reported the missing item to a nurse, who searched for it but did not find it. The nurse did not report the missing item to the administration, and as a result, the grievance was not documented or resolved as per the facility's policy. Interviews with staff confirmed that the missing phone charger was reported to a CNA and an LPN, but neither took the necessary steps to escalate the issue to the administration. The Director of Nursing (DON) and the Administrator were unaware of the missing item until the surveyor's investigation. This failure to follow the grievance policy resulted in the resident's grievance not being addressed or resolved in a timely manner.
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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) |
|---|---|---|---|---|
| Capitol House Nursing And Rehab Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Flannery Oaks Guest House | 2.2 mi | ★★★★★ | 0 | 0 |
| White Oak Post Acute Care | 2.4 mi | — | 21 | 1 |
| St Clare Manor Nursing And Rehabilitation | 2.4 mi | ★★★★★ | 4 | 0 |
| The Woodleigh Of Baton Rouge | 2.7 mi | ★★★★★ | 1 | 0 |
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