Heritage Manor of Baton Rouge II

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received assistance with incontinent care for 2 (#7 and #85) of 4 residents reviewed for ADLs. Review of the facility's policy titled Toileting Resident, with a revision date of 01/24, revealed the following, in part: PurposeResidents are toileted safely on a routine basis in a timely manner according to their individual plan of care. Resident #7Review of Resident #7's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Dementia and Generalized Muscle Weakness. Review of Resident #7's Significant Change MDS with an ARD of 01/20/2026 revealed she had a BIMS of 12, which indicated she was moderately cognitively impaired. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure controlled drugs were accurately reconciled for 2 of 2 (Medication Cart A and Medication Cart B) medication carts observed for controlled drug reconciliation. Review of the facility's policy titled, Drug-Controlled Substances with a revision date of 09/2025 revealed the following:Controlled medications are to be signed out on Individual Resident Narcotics Record(Form NS-618) at the time they are to be administered. An observation of Medication Cart A on 03/03/2026 at 10:30 a.m. with S3LPN revealed Resident #46's Alprazolam 0.5 mg medication packet contained 55 tablets. Review of the Individual Resident Narcotics Record showed on 03/03/2026 at 7:00 a.m., S3LPN documented administration of one tablet with a remaining balance of 54 tablets. On 03/03/2026 at 10:31 a.m., an interview was conducted with S3LPN. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure physical restraints were not imposed for the purpose of staff convenience and were used to treat a resident's medical symptoms for 1 (#113) of 2 residents reviewed for restraints. Review of the facility's policy titled Restraints and Safety Devices, with a revision date of 10/22, revealed the following, in part:It is the philosophy of this facility that a resident has the right to be free from any physical or chemical restraints not required to treat the residents' medical symptoms. Physical Restraint DefinitionAny manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, restricts freedom of movement or normal access to one's body. [...]

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#91) of 2 residents reviewed for enteral feedings. The facility failed to ensure the enteral feeding bag was appropriately labeled.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain accurate records in accordance with professional standards of practice by failing to ensure medication administration was accurately documented on the MAR for 3 of 3 (#1, #2, and #3) residents in the sample. This deficient practice had the potential to affect a current census of 119 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing perineal care to a resident who was on Enhanced Barrier Precautions (EBP) for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for infection control.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure an allegation of neglect was reported immediately, but not later than 2 hours after the incident occurred to the State Survey Agency and local law enforcement in accordance with State law for 1 (#3) of 4 ( #1, #2, #3, and #R1) residents reviewed for abuse. The provider failed to report Resident #3's elopement from the facility on 02/08/2025 to local law enforcement and the state agency. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open EPS case against family members. [...]

Inspectors wroteBased on record reviews and interviews, the provider failed to develop and implement a Comprehensive Person-Centered Care Plan to meet the needs of 1 (#3) of 7 (#1, #2, #3, #R1, #R2, #R3, and #R4) sampled residents. The facility failed to ensure staff were aware of Resident #3's active protective order and an open Elderly Protective Service (EPS) case against 3 family members. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open EPS case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents received adequate supervision to prevent elopement from the facility for 1 (#3) of 4 (#3, #R2, #R3, and #R4) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open Elderly Protective Services (EPS) case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. CNA staff went to check on the resident and realized she had been removed from the facility. [...]

Inspectors wroteBased on interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure: 1. Administrative Staff communicated resident care needs to direct care staff to prevent elopement for 1 (#3) of 7 (#1, #2, #3, #R1, #R2, #R3, and #R4) sampled residents; and 2. Administrative staff reported an elopement to the state agency and local police in accordance with state law for 1 (#3) of 4 (#1, #2, #3, and #R1) residents reviewed for abuse. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status for 3 (#3, #R2, and #R3) of 7 (#1, #2, #3, #R1, #R2, #R3, and #R4) sampled residents by failing to ensure Residents #3, #R2, and #R3 were coded correctly for wander/elopement alarms.

Inspectors wroteBased on observations, and interviews the facility failed to ensure a safe, functional, sanitary and comfortable environment. The facility failed to ensure: 1.) Resident air conditioners (AC) were sanitary in Room B and Room E; 2.) Ceiling Tiles were maintained in clean and functional manner on Hall A and Room B; 3.) Floor tiles were maintained in a safe and functional manner in Room C ; and 4.) Bath D was maintained in a sanitary manner for staff and the public.

Inspectors wroteBased on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASARR) Level II by failing to incorporate PASARR Level II determinations and recommendations into each resident's assessment and care plan for 4 (#2, #10, #27 and #100) of 5 (#2, #10, #27, #29 and #100) residents reviewed for PASARR.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident received trauma-informed care and services in accordance with professional standards of practice for 1 of 1 (#100) residents reviewed with a diagnosis of Post-Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% for 2 (#23 and #31) of 4 (#23, #31, #45, and #75) residents observed during medication administration. A total of 39 opportunities were observed with 16 medication errors, which resulted in a medication error rate of 41.03%. This failed practice had the potential to affect any of the 116 residents currently residing in the facility.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure medication carts were free of loose pills for 1 (Med Cart B) of 2 (Med Cart A and Med Cart B) medication carts observed. This deficient practice had the potential to effect the 116 residents currently residing in the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 1 (#30) of 3 (#30, #82, and #88) resident's reviewed for perineal care. The facility failed to ensure staff performed hand hygiene and proper glove use for Resident #30 during perineal care.

Inspectors wroteBased on record reviews, and interviews, the facility failed to protect each residents' right to be free from physical abuse for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse by Resident #2.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident's chart contained the required documentation in the medical record for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for emergency transfers.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide documentation of the notice of discharge to the Ombudsman for a facilitated initialed discharge of a hospitalized resident for 1 (#1) of 3 (#1, #2, and #3) resident's records reviewed. This deficient practice had the potential to affect any of the 119 residents who reside in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a reentry MDS assessment was completed and transmitted timely for 1 (#2) of 3 (#1,#2,#3) residents reviewed for Resident Assessment.

Inspectors wroteBased on observation, interview and record review, the provider failed to ensure physician's orders were implemented for 1 (#3) of 2 (#1 and #3) residents sampled for tube feedings.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while performing incontinent care for 1 (#R1) of 2 (#3 and #R1) residents reviewed for Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing data was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 122 residents residing in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 3(#14, #33, #71) of 7 (#14, #28, #33, #39, #40, #44, #71) sampled resident records reviewed for PASRR.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to affect 110 residents who were served meals from the kitchen.

Inspectors wroteBased on observations and interviews the facility failed to ensure expired medications and biologicals were not available for use and administration to residents as evidenced by: Expired medications, loose tablets, and, medications with no open dates being stored in [NAME].

Inspectors wroteBased on interviews, observations, and policy review the facility failed to maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of disease and infection for 2 of 2 Residents (#210, #94,) observed during medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from sexual abuse by Resident #1 for 2 (#2 and #3) of 3 (#2, #3, and #4) residents reviewed for abuse. This deficient practice resulted in an immediate jeopardy situation on 10/11/2023 at 5:07 a.m. when Resident #1, a resident with a history of sexually inappropriate behaviors, touched Resident #2, a severely cognitively impaired resident, on the vagina in the facility's dining room. At 5:07 a.m., S5CNA observed Resident #1 touching Resident #2 inappropriately. At that time, S5CNA, alerted S6LPN of the incident. S6LPN failed to report the incident to administration and failed to implement adequate interventions after the incident. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an allegation of sexual abuse was reported to the facility administrator immediately, but not later than 2 hours after the allegation was made for 1 (#2) of 3 (#2, #3, and #4) residents reviewed for abuse. S6LPN failed to notify administration of an allegation Resident #1 sexually abused Resident #2. This deficient practice resulted in an immediate jeopardy situation on 10/11/2023 at 5:07 a.m. when Resident #1, a resident with a history of sexually inappropriate behaviors, touched Resident #2, a severely cognitively impaired resident, on the vagina in the facility's dining room. At 5:07 a.m., S5CNA observed Resident #1 touching Resident #2 inappropriately. At that time, S5CNA, alerted S6LPN of the incident. [...]