Landmark of Baton Rouge

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 (Cart A and Cart B) of 3 medication carts reviewed. Review of the facility's policy titled Medication Storage with a revision date of 11/2017 revealed, the following, in part: Medication storage shall meet all applicable federal, state and local guidelines. On 02/23/2026 at 11:40 a.m., an observation was made of Cart B with S6LPN, which revealed fifteen loose and unlabeled pills on the bottom of the cart's drawers. On 02/23/2026 at 11:52 a.m., an interview was conducted with S6LPN. She stated the nurses should check the medication carts daily for loose medications. S6LPN confirmed the above pills were loose and unlabeled in the cart and should not have been. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure dietary services were provided in accordance with professional standards for food service safety for the 117 residents served a meal tray from the kitchen. The facility failed to ensure:Staff routinely performed temperature checks on the food served to residents; and Thawing of meat in the refrigerator, in a drip-proof container.1. Review of facility's Policy titled Sanitary Conditions of the food service department with a revision date of 05/2018 revealed the following, in part: Policy: Facilities and equipment used in the preparation and serving of food provided to residents are safe and sanitary. Review of the facility's policy titled, Monitoring temperatures of cooked foods, last reviewed 02/2022, revealed the following in part: Policy: [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident's room were clean and maintained in a sanitary manner for 1 (#15) of 3 (#15, #23, and #34) sampled residents investigated for environment. The facility failed to ensure Resident #15's room was properly cleaned. A review of Resident #15's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Hemiplegia And Hemiparesis Following Cerebrovascular Disease Affecting Left Dominant Side, Dysphagia, Cognitive Communication Deficit and Aphasia On 02/24/2026 at 1:58 p.m., an observation was conducted of Resident #15's bathroom. Resident #15's bathroom was noted with the following: one foot in front of the commode was a clear wet liquid with a dried brown substance approximately 4 cm in length. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure oxygen tubing was labeled for 1 (#14) of 26 residents reviewed in the final sample.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure a resident had a physician's order before being allowed to self-administer medication, including routine medication, for 1 (#51) of 26 residents reviewed in the final sample.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure it was free of significant medication errors for 1 (#126) of 11 residents reviewed for medication administration. Review of Resident #126's clinical record revealed he was admitted to the facility on [DATE] with a diagnosis of Sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA). Review of Resident #126's admission MDS with an ARD of 02/24/2026 revealed it was still in progress and the BIMS had not been completed. Review of Resident #126's Discharge Orders from a local hospital dated 02/19/2026 revealed the following antibiotic order:Daptomycin-Sodium Chloride Intravenous Solution. Inject 1000 mg into the vein in the morning for 19 days. Indication: Bacteria in the blood. Review of Resident #126's Physician Orders since admission revealed, in part: Start date 02/20/2026. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infections for 1 (#15) of 2 residents reviewed for having a feeding tube. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) when providing care to Resident #15, who was on Enhanced Barrier Precautions (EBP). A review of Resident #15's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, gastrostomy status. A review of Resident #15's current Physician Orders revealed the following, in part: Order Start Date: 07/01/2024 Enhanced Barrier Precautions - gown and gloves to be worn during high contact resident care activities (device care - feeding tube). [...]

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#1) of 3 sampled residents reviewed for witnessed falls. The facility failed to ensure nursing staff accurately documented Resident #1's witnessed fall.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 3 (#5, #60 and #122) residents out of a total of 27 sampled residents. The facility failed to ensure: 1. Resident #5 was coded correctly for PASRR (Pre-admission Screening and Resident Review); 2. Resident #60 was coded correctly for pressure ulcers; and 3. Resident #122 was coded correctly for discharge.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with mental disorders had an accurate Pre-admission Screening for 1 (#118) of 5 (#5, #6, #10, #63, and #118) residents reviewed for Pre admission Screening and Resident Review (PASRR).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (#55 and #60) of 2 (#55 and #60) residents observed with catheters. The facility failed to ensure: 1. Staff used proper hand hygiene and infection control techniques when providing catheter care for Resident #55; and 2. Resident #60's catheter bag remained off of the floor.

Inspectors wroteBased on interviews and record reviews, the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 (#2 and #R4) of 3 (#1, #2, and #R4) residents reviewed for resident rights. The facility failed to ensure: 1. Residents #2 and #R4 were able to choose the type of bath they received; and 2. Resident #R4 was able to choose when she wanted to get back in bed.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene for 2 (#R4, and #R5) of 5 (#1, #2, #3, #R4, and #R5) residents reviewed for ADLs. The facility failed to ensure: 1. Residents #R4 and #R5 received baths as scheduled; and 2. Resident #R4 was provided incontinence care timely after calling for assistance. 1. Resident #R4 Review of Resident #R4's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Muscle Wasting and Atrophy, Age-Related Physical Debility, and Morbid Obesity. Review of Resident #R4's Quarterly MDS with an ARD of 02/15/2024 revealed, in part, she had a BIMS of 15, which indicated intact cognition. Further review of the MDS revealed she was dependent on staff for showers/baths. [...]

Inspectors wroteBased on record review, interviews, and observations, the facility failed to have sufficient certified nursing assistant staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 (#1, #2, #R4 and #R5) of 6 (#1, #2, #3, #R4, #R5, and #R6) residents reviewed for staffing.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents during a Hoyer Lift transfer for 1 (#R6) of 3 (#2, #R4, and #R6) residents reviewed who required a Hoyer Lift for transfers.

Inspectors wroteBased on record review and interviews, the facility failed to implement a comprehensive person-centered care plan for 1 (#35) of 25 residents reviewed in the final sample. The facility failed to ensure specialty consult appointments were scheduled as ordered by the physician.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure the correct medication was prepared prior to medication administration for 1 (#22) of 5 (#22, #23, #34, #69, and #319) residents observed during medication administration.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 (Cart A and Cart B) of 3 (Cart A, Cart B, and Cart C) medication carts observed. The facility failed to ensure: 1. Insulin pens were labeled with the date opened and 2. Insulin pens were discarded 28 days after the date opened.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure nursing staff sanitized insulin pen stoppers prior to attaching an insulin pen needle for 2 (#22 and #34) of 3 (#22, #23, and #34) residents reviewed for insulin administration.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident was given the appropriate treatment and services to maintain his or her ability to carry out activities of daily living for 1 (#1) of 5 (#1, #2, #3, #4, and #5) residents reviewed for ADLs. The facility failed to ensure Resident #1 was provided toileting when requested.