Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 The Woodleigh Of Baton Rouge during CMS and state inspections, most recent first.
The facility did not ensure that code status documentation was consistent across medical records for two residents. In both cases, discrepancies existed between the LaPost forms, physician orders, and EHRs, with staff confirming that they would follow the physical chart in emergencies, potentially leading to actions not aligned with the residents' wishes. Staff and leadership acknowledged that all records should match to honor resident preferences.
A resident with multiple chronic conditions requiring oxygen therapy was found to have oxygen tubing that was not labeled with the date it was last changed. Observations and staff interviews confirmed that the tubing should have been changed and labeled weekly, but this was not done, resulting in a deficiency in respiratory care.
Surveyors found that an expired medication was still available for use in one medication cart, and an opened bottle of Vitamin D tablets was not labeled with the date it was opened. Both an LPN and the DON confirmed these deficiencies during interviews.
Surveyors found an outdoor trash dumpster with its door open and a bag containing soiled briefs and gloves hanging out, along with scattered trash such as plastic cups, utensils, gloves, and other items on the ground. Staff confirmed the area should be kept clean and the dumpster doors closed, but maintenance did not ensure proper containment and disposal of waste.
A resident with an indwelling urinary catheter was not placed on Enhanced Barrier Precautions as required by facility policy, and an LPN performed catheter care using only gloves instead of both gown and gloves. Staff interviews confirmed that the necessary precautions and signage were not implemented for the resident, despite the presence of a urinary catheter and related diagnoses.
A resident with significant mobility impairments and a care plan requiring the call light to be within reach was repeatedly observed with the call light on the floor and inaccessible. Staff and the DON confirmed the call light should have been accessible at all times, in accordance with facility policy and the resident's documented needs.
A resident's unopened Ipratropium-Albuterol Solution was observed left on the bedside table on two occasions, rather than being stored in a locked medication cart as required by facility policy. Both an LPN and the DON confirmed that medications should not be left at the bedside and acknowledged the nurse's responsibility for proper storage.
A resident who returned from the hospital with a left arm in a sling was documented in the MDS as needing only setup or cleanup help for meals, but observations and staff interviews confirmed the resident was actually dependent on staff for feeding. The MDS coordinator and DON confirmed the assessment was based on documentation that did not accurately reflect the resident's true needs.
A resident with moderate cognitive impairment and a history of falls, who was always incontinent but aware of toileting needs, was not provided with a bowel and bladder program or scheduled toileting. Staff instructed the resident to use briefs instead of assisting with commode transfers, and no interventions were in place to promote continence, despite the resident's ability and preference to use the toilet.
A resident with significant physical limitations and moderate cognitive impairment was dependent on staff for eating, but ADL documentation inconsistently recorded the level of assistance provided. Staff interviews and observations confirmed the resident required total dependence for eating, yet records showed varying levels of assistance, resulting in inaccurate documentation.
A resident suffered fractures in both femurs after a CNA inappropriately used a slide board for a transfer. The CNA had received computer-based training but had not completed a return demonstration to ensure competency. The facility lacked consistent training and competency checks for slide board transfers, leading to the incident.
The facility failed to ensure all licensed nursing and CNA staff had documented new hire and annual competency demonstrations for their roles. Personnel files of five staff members showed no evidence of completed competencies, and interviews confirmed that CNAs did not demonstrate skills before working independently or annually. The DON acknowledged the lack of competency demonstrations despite regular in-service trainings.
The facility failed to ensure accurate MDS assessments for two residents reviewed for PASRR. Both residents had approved Level II PASRRs, but their Annual MDS assessments incorrectly indicated they were not evaluated for PASRR. Staff confirmed the assessments should have included the state Level II PASRR but did not.
The facility failed to ensure that nurse staffing data was posted in a prominent location accessible to residents and visitors. The daily nursing staff sheet was found behind the nurses' station in a restricted area, confirmed by the DON.
The facility failed to ensure PRN orders for psychotropic medications were limited to 14 days for four residents. Interviews with the pharmacist and DON confirmed that PRN Lorazepam orders for these residents had no stop dates, violating the 14-day limit requirement.
A resident reported missing clothing and a blanket, but the facility failed to log the grievance or resolve the issue promptly. Staff did not follow the facility's policy, resulting in the resident not being informed of any findings or corrective actions.
The facility failed to ensure medications were administered safely and timely by leaving medications at the bedside for a resident. The resident confirmed that the medications were his morning doses and that the LPN had left them for him to take when he was ready because he was feeling nauseated. The LPN verified that she did not observe the resident take his medications, which she acknowledged she should have done. The DON confirmed that medications should not have been left at the resident's bedside and that the nurse should have observed the resident taking his medications.
A resident with hemiplegia, hemiparesis, and type 2 diabetes mellitus did not receive necessary nail care, resulting in long, dirty fingernails despite multiple requests and observations by staff. Inconsistencies in staff responsibilities and communication contributed to the deficiency.
A resident with Unspecified Protein-Calorie Malnutrition did not consistently receive the prescribed House Shake Supplement with meals, as ordered by the healthcare provider. Observations and interviews confirmed that the supplement was often missing from the resident's meal trays, despite the dietary and nursing staff being aware of the order.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that all medical records accurately reflected residents' wishes regarding code status for two residents. For one resident, the physical chart contained a LaPost form signed by the resident's Power of Attorney and physician indicating Do Not Resuscitate (DNR), while the physician orders and electronic health record (EHR) listed the resident as Full Code. Staff interviews confirmed that the LaPost and EHR did not match, and the Director of Nursing acknowledged that all records should reflect the resident's end-of-life wishes but did not. For another resident, the physical chart's LaPost form indicated Full Code, while the hospice binder contained a LaPost signed by a family member and physician indicating DNR. The physician orders and EHR also listed DNR, but the physical chart did not match. Staff interviews revealed that in an emergency, staff would refer to the physical chart, which could result in actions inconsistent with the resident's wishes. The resident confirmed a desire for CPR, but documentation across records was inconsistent, and staff acknowledged that all records should be consistent.
Failure to Label and Change Oxygen Tubing as Required
Penalty
Summary
The facility failed to provide necessary care and services for respiratory care in accordance with professional standards for one resident. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Diastolic Heart Failure, Ischemic Cardiomyopathy, and Asthma, had a physician's order for oxygen therapy at 2 liters per nasal cannula as needed. Observations on two consecutive days revealed that the resident's oxygen tubing was not labeled with the date it was last changed. Interviews with nursing staff, including an LPN and the Director of Nursing, confirmed that the tubing should have been changed and labeled weekly, and that it was the nurse's responsibility to do so. The failure to label and change the oxygen tubing as required constituted a deficiency in the provision of respiratory care.
Failure to Properly Store and Label Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of medications in accordance with accepted professional standards. Specifically, in one medication cart, a card containing 21 tablets of Hyoscyamine Sulfate Sublingual 0.125 mg for a resident was found with a discard after date that had already passed, indicating the medication was expired but still available for use. Additionally, a bottle of Vitamin D 10 mcg tablets was found opened without a label indicating the date it was opened. During interviews, both the LPN and the Director of Nursing confirmed these findings and acknowledged that the expired medication should have been discarded and the opened bottle should have been labeled with the open date.
Improper Containment and Disposal of Outdoor Garbage and Refuse
Penalty
Summary
Surveyors observed that one of the facility's two outdoor trash dumpsters had its door open, with a clear plastic bag containing soiled briefs and gloves hanging out of the lid. Additional scattered trash, including a plastic bag, plastic cups, plastic utensils, gloves, a green cloth, empty juice containers, and other unidentifiable paper items, was found on the ground around the dumpster. Multiple staff interviews confirmed these observations and acknowledged that maintenance staff were responsible for keeping the dumpster area clean and that the dumpster doors should be kept closed with the surrounding area free of trash.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically by not implementing Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. According to the facility's policy, residents with indwelling medical devices, such as urinary catheters, should be placed on EBP, which includes the use of gown and gloves during high-contact care activities. Observations revealed that there was no EBP signage on the resident's door, and the resident was not placed on EBP despite having a urinary catheter. Interviews with staff, including the Director of Nursing and the Infection Preventionist, confirmed that the resident should have been on EBP and that the required signage and precautions were not in place. Additionally, during an observation of catheter care, an LPN performed the procedure wearing only gloves and not a gown, contrary to the facility's policy for EBP. The LPN stated that only gloves were necessary for catheter care and confirmed that she did not use a gown. The Infection Preventionist also confirmed that staff should wear both gown and gloves when providing direct care to residents on EBP and acknowledged that the resident with the urinary catheter was not on the appropriate precautions. The resident in question had a history of benign prostatic hyperplasia with urinary retention and a urinary tract infection, and had an indwelling catheter in place at the time of the deficiency.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia, hemiparesis, left hand and elbow contractures, and a need for extensive assistance with activities of daily living was found to have their call light out of reach on multiple occasions. The resident's care plan specifically included interventions to keep the call light within reach due to their decreased mobility, history of falls, and self-care deficits. Despite these documented needs and interventions, observations on two consecutive days revealed the call light lying on the floor at the foot of the bed, not accessible to the resident while she was sitting up in bed. Interviews with the resident, a CNA, and the Director of Nursing confirmed that the call light was not within reach and that it should have been accessible at all times when the resident was in her room. The facility's policy also required that each resident be provided with a means to call staff for assistance from their bed. The failure to ensure the call light was within reach represented a lack of reasonable accommodation for the resident's needs and preferences as outlined in her care plan and the facility's policy.
Medication Storage Policy Not Followed
Penalty
Summary
The facility failed to ensure that medications were stored safely and in accordance with professional standards, as required by its own policy. During observations, an unopened package of Ipratropium-Albuterol Solution was found left on the bedside table of a resident on two separate occasions. The resident, who was cognitively intact and had diagnoses including wheezing and acute cough, confirmed that the medication belonged to her. According to the facility's policy, all medications are to be stored in locked compartments and only accessible to authorized personnel, with nursing staff responsible for maintaining safe storage practices. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the medication should not have been left at the bedside and should have been stored in the locked medication cart. Both staff members acknowledged that it was the nurse's responsibility to ensure proper storage of medications. The failure to secure the medication as per policy constituted a lapse in maintaining professional standards of quality for medication storage.
Inaccurate Resident Assessment for Eating Assistance
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the actual status of a resident regarding the assistance required for eating. A review of the clinical record for a resident who was readmitted to the facility with a left upper extremity sling revealed that the Quarterly MDS Assessment indicated the resident only required setup or cleanup assistance for meals. However, direct observation showed that the resident was being fed by staff, with one staff member feeding the resident and another holding a cup and placing a straw to the resident's lips. Multiple staff interviews confirmed that since the resident's return from the hospital with a sling, he had been dependent on staff for feeding due to limited range of motion. The MDS coordinator acknowledged that the assessment was based on electronic health record documentation, which should have accurately reflected the resident's needs, but was unaware of the resident's dependency for meals. The DON also confirmed that the MDS assessment relied on ADL documentation, which should accurately represent the resident's status.
Failure to Provide Bowel and Bladder Continence Services
Penalty
Summary
The facility failed to provide appropriate services to restore or maintain normal bowel and bladder function for a resident who was always incontinent of bowel and bladder. The resident, who had a history of septic arthritis, falls, hemiplegia, and required assistance with personal care, was assessed as moderately cognitively impaired but was aware of his need to use the toilet. Despite this, the care plan interventions were limited to the use of adult briefs, checking every two hours, and encouraging the resident to call for assistance. There was no evidence of a structured bowel and bladder program or scheduled toileting to promote continence. Multiple incident reports documented the resident's attempts to use the bathroom independently, resulting in falls and near-misses. Interviews with the resident, his responsible party, and several staff members revealed that staff routinely instructed the resident to use the brief and did not offer or implement a toileting schedule or regular assistance to the commode, despite the resident's expressed preference and ability to participate. Nursing staff confirmed that a bowel and bladder program had not been initiated for the resident, and there were no current interventions in place to promote continence.
Inaccurate ADL Documentation for Dependent Resident
Penalty
Summary
The facility failed to ensure accurate documentation of Activities of Daily Living (ADL) care for one resident who required assistance with eating. The resident, who had a history of septic arthritis in the left shoulder, hemiplegia, and hemiparesis following a cerebral infarction affecting the right side, was admitted and readmitted with significant physical limitations. Clinical records and staff interviews confirmed that the resident had a sling on the left arm and limited movement in the right arm, resulting in total dependence on staff for eating. However, the ADL documentation for the resident inconsistently recorded the level of assistance provided, with entries ranging from limited assistance to total dependence, despite staff consistently reporting that the resident was dependent on staff for eating. Observations showed staff feeding the resident and assisting with drinking, further supporting the need for total dependence coding. Multiple staff members, including CNAs, LPNs, and therapy staff, confirmed the resident's inability to feed himself due to his physical condition. The MDS coordinator acknowledged that the ADL documentation was inaccurate and should have reflected total dependence for eating, as the resident was being fed by staff throughout the reviewed period.
Inadequate Training on Slide Board Transfers
Penalty
Summary
The facility failed to ensure that each nurse aide was competent in transferring a resident using a slide board, resulting in actual harm to a resident. On 04/02/2024, a CNA inappropriately used a slide board to transfer a resident, causing the resident to fall to the floor. The resident initially denied pain but later experienced severe pain, leading to the discovery of fractures in both femurs, which required surgical intervention. The resident was cognitively intact and dependent on staff for transfers, with a care plan that included the use of a slide board for transfers due to decreased mobility and other health conditions. Interviews and record reviews revealed that the CNA had received computer-based training on slide board transfers but had not completed a return demonstration to ensure competency. The facility's training materials indicated that caregivers should position themselves in front of the patient during transfers, but the CNA was standing behind the resident during the incident. Further interviews with staff indicated that there was no consistent training or competency checks for slide board transfers, and the physical therapy staff had not provided demonstrations or training to the CNAs. The Director of Nursing confirmed that new CNA employees did not complete a slide board/transfer competency skills check upon hire or annually. The facility had conducted an in-service on safe transfers in November 2023, but staff did not complete a return demonstration to ensure competency. The CNA involved in the incident had completed computerized training in December 2023 but did not attend the in-service training. This lack of proper training and competency checks led to the inappropriate use of the slide board and the subsequent injury to the resident.
Failure to Document Staff Competency Demonstrations
Penalty
Summary
The facility failed to ensure all licensed nursing and certified nursing assistant staff had documented new hire and annual competency demonstrations for all skills related to their expected roles. This deficiency was identified in the personnel files of five staff members, including CNAs and LPNs, who had no documented evidence of competencies being completed upon hire or annually. Interviews with staff confirmed that CNAs did not demonstrate competency skills before working independently or annually, and the Director of Nursing acknowledged that while in-service skills trainings were conducted, there were no competency demonstrations by the employees themselves.
Inaccurate MDS Assessments for PASRR
Penalty
Summary
The facility failed to ensure that resident MDS assessments accurately reflected the residents' status for two residents reviewed for PASRR. Resident #13, who was admitted with diagnoses including Major Depressive Disorder, Bipolar Disorder, Persistent Mood Affective Disorder, and Generalized Anxiety Disorder, had an approved Level II PASRR. However, the Annual MDS with ARD of 12/21/2023 incorrectly indicated that the resident was not evaluated for PASRR. Similarly, Resident #18, admitted with Schizoaffective Disorder and Bipolar Disorder, also had an approved Level II PASRR, but the Annual MDS with ARD of 01/04/2024 incorrectly indicated that the resident was not evaluated for PASRR. Interviews with staff confirmed that the MDS assessments should have included the state Level II PASRR but did not.
Failure to Post Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to ensure that nurse staffing data, including resident census and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. On 05/28/24 at 11:55 a.m., an observation revealed that the daily nursing staff sheet was located behind the nurses' station in the medical record room, which was restricted to staff only. This was confirmed during an interview with the Director of Nursing (DON) at 12:18 p.m., who acknowledged that the daily nursing staff sheet was not accessible for residents or visitors to view.
Failure to Limit PRN Orders for Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for four residents. Resident #17 was admitted with diagnoses including Unspecified Dementia, Generalized Anxiety Disorder, and Insomnia. The resident had a PRN order for Lorazepam 1 mg tablet every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath, with no stop date. Similarly, Resident #35, admitted with Alzheimer's Disease, Schizoaffective Disorder, Unspecified Mood Disorder, and Anxiety, had a PRN order for Lorazepam 1 mg tablet every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath, also without a stop date. Resident #58, with Vascular Dementia, Major Depressive Disorder, and Schizoaffective Disorder, had a PRN order for Lorazepam 1 mg tablet every 4 hours as needed for anxiety and/or shortness of breath, again with no stop date. Resident #69, diagnosed with Unspecified Dementia, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, and Anxiety Disorder, had a PRN order for Lorazepam 1 mg tablet every 4 hours as needed for shortness of breath, anxiety, and/or trouble sleeping, without a stop date as well. Interviews with the pharmacist and the Director of Nursing (DON) confirmed that all PRN antipsychotic medications, including Lorazepam, required an end date of no longer than 14 days following the start of the medication. The pharmacist responsible for completing the facility's pharmaceutical consultation reports for Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) stated that PRN antipsychotic medications should have an end date. The DON confirmed the presence of PRN Lorazepam orders without stop dates for Residents #17, #35, #58, and #69, indicating a failure to comply with the 14-day limit requirement for PRN psychotropic medications.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances for a resident who reported missing clothing and a blanket. The resident, who was cognitively intact, reported the missing items to staff but did not receive a resolution. The facility's grievance log did not document the grievance, and staff interviews revealed that the missing items were not reported to the Administrator as required by the facility's policy. The resident reported the missing items to a CNA and the housekeeping supervisor, but neither took the necessary steps to log the grievance or inform the Administrator. The facility's policy requires grievances to be investigated and resolved within five working days, but this was not followed in the case of the missing items. The Director of Nursing and the Social Services Director confirmed that no grievance was filed for the missing items, and the Administrator stated that the grievance should have been logged and resolved within the specified timeframe. The failure to follow the grievance policy resulted in the resident not being informed of the findings or any corrective actions regarding the missing items.
Failure to Administer Medications Safely and Timely
Penalty
Summary
The facility failed to ensure medications were administered safely and timely by leaving medications at the bedside for a resident. During an observation, a plastic medication cup containing 7 pills was found on the bedside table of a resident who was awake and alert. The resident confirmed that the medications were his morning doses and that the LPN had left them for him to take when he was ready because he was feeling nauseated. The LPN verified that she did not observe the resident take his medications, which she acknowledged she should have done. The Director of Nursing confirmed that medications should not have been left at the resident's bedside and that the nurse should have observed the resident taking his medications. The resident's clinical record revealed multiple diagnoses, including Polyneuropathy, Acquired Absence of both legs above the knee, Benign Prostatic Hyperplasia, Moderate Protein Calorie Malnutrition, Peripheral Vascular Disease, and Unspecified Pain. The resident was cognitively intact with a BIMS score of 15, and his physician orders included several medications to be taken daily.
Failure to Provide Necessary Nail Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not trim the fingernails of a resident with hemiplegia, hemiparesis, and type 2 diabetes mellitus. The resident, who had intact cognition and required moderate assistance for ADLs, was observed with fingernails that were 1/2 to 1 cm long and had black debris underneath. Despite the resident's requests for nail trimming, the facility staff did not provide this care adequately. Interviews with various staff members, including CNAs and LPNs, revealed inconsistencies and misunderstandings regarding who was responsible for trimming the nails of diabetic residents. While CNAs were expected to clean nails, they deferred trimming to nurses due to the residents' diabetic status. However, the Director of Nursing stated that any staff member could trim fingernails, regardless of the resident's diabetic condition. This lack of clear protocol and communication led to the resident's nails being neglected, despite multiple opportunities for care during regular shower routines and daily assessments.
Failure to Provide Prescribed Nutritional Supplement
Penalty
Summary
The facility failed to ensure a resident was offered a therapeutic diet as ordered by the healthcare provider. Resident #3, who was admitted with a diagnosis of Unspecified Protein-Calorie Malnutrition, had a physician's order for a House Shake Supplement three times a day with all meals. Despite this order, observations and interviews revealed that Resident #3 did not consistently receive the prescribed Mighty Shake with her meals. On one occasion, it was noted that Resident #3's breakfast tray did not include the Mighty Shake, and she had only consumed approximately 25% of her meal. Interviews with CNAs and an LPN confirmed that the resident was supposed to receive the supplement with all meals but did not always get it. The CNAs and LPN acknowledged that the kitchen staff should have included the supplement on the meal tray, and if it was missing, the CNAs should have retrieved it from the kitchen. Further interviews with the Dietary Manager and the Director of Nursing revealed that the process for ensuring the supplement was provided involved updating meal tickets and notifying kitchen staff of new orders. The Dietary Manager confirmed that the order for the Mighty Shake was resumed due to the resident's weight loss after hospitalization, and the supplement should have been provided with each meal. The Director of Nursing verified that the kitchen staff were responsible for sending the supplements on the meal trays and confirmed that Resident #3 should have received the Mighty Shake with her breakfast. The failure to consistently provide the prescribed nutritional supplement contributed to the resident's ongoing nutritional issues and weight fluctuations.
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What surveyors actually found near you
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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.
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) |
|---|---|---|---|---|
| Pines Retirement Center Of Baton Rouge | 0.3 mi | ★★★★★ | 10 | 0 |
| Flannery Oaks Guest House | 1.1 mi | ★★★★★ | 0 | 0 |
| Capitol House Nursing And Rehab Center | 1.8 mi | ★★★★★ | 0 | 0 |
| White Oak Post Acute Care | 2.4 mi | — | 12 | 1 |
| The Guest House Care Center | 2.7 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.