Baton Rouge Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to develop and implement a comprehensive person-centered care plan. The facility failed to:1. Ensure Resident #15's call light was within reach and covered with bright tap; and 2. Ensure Resident #71 was care planned as a safe smokerThis deficient practice had the potential to affect a current census of 94 residents. Review of the facility's policy titled, Call Light/Call Pager Systems with an effective date of date of 10/27/2014, revealed the following, in part:Policy Statement 1.1 Purpose: To provide a means of communication to staff for notification of resident needs and a system of communication among staff in the facility; including emergency notifications.1.5 PolicyThe call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Resident #15Review of Resident #15's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to follow standing physician orders and notify the physician of blood glucose reading over 400 for 2 (#7 and #15) of 3 (#7, #12, and #15) residents reviewed for insulin administration.Review of the facility's Blood Glucose Monitoring standing orders, updated on 12/31/2024 revealed the following, in part:All admissions/readmissions with a diagnosis of Diabetes should have accuchecks. Administer Novolog/Humalog insulin SQ as indicated in the parameters below.If glucose is greater than 400 give 10 units and notify provider for additional ordersResident #7Review of Resident #7's Clinical Record revealed he was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus.Review of Resident #7's current physician orders revealed the following, in part:NovoLOG FlexPen 100 unit/mL (Insulin Aspart)-Inject as per sliding scale:401 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 2 (#15 and #99) of 24 residents reviewed during the initial pool. Review of the facility's policy titled, Call Light/Call Pager Systems with an effective date of date of 10/27/2014, revealed the following, in part:Policy Statement 1.1 Purpose: To provide a means of communication to staff for notification of resident needs and a system of communication among staff in the facility; including emergency notifications.1.5 PolicyThe call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Resident #15Review of Resident #15's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction and Hemiplegia and Hemiparesis following Cerebral Vascular Accident. Review of Resident #15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure a resident's bath was accurately documented for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for ADL's (Activities of Daily Living). Findings: Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #3's current Care Plan revealed the following, in part; Problem: I have an ADL self-care performance deficit related to Non-Traumatic Intracranial Hemorrhage with Right Sided Hemiplegia. Interventions: I am totally dependent on staff to provide a bath/shower. Review of Resident #3's Bath Flowsheet dated March 2025 to May 12, 2025 revealed the residents scheduled bath days were Monday, Wednesday, and Friday. Further review revealed Resident #3 did not have a documented bath on Monday 03/24/2025, Friday 03/28/2025, and Monday 04/28/2025. On 05/13/2025 at 1:52 p.m., an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure each resident was treated with respect and dignity and cared for them in a manner that promoted enhancement of quality of life for 4 of 4 (#1, #21, #70, and #82) residents reviewed for dignity. Findings: Review of facility's policy titled, Resident Rights, dated 12/2026, revealed, in part: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: b. Be treated with respect, kindness, and dignity. Review of S8CNA's employee file revealed the following: Notice of Expected Improvement Date: 09/28/2024 Nature of Occurrence: Resident #70 reported S8CNA spoke to her in a very strong tone. Expected Improvement or Standard: S8CNA was counseled by her immediate supervisor and the administrator. S8CNA was advised improvement was expected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 2 (#2 and #83) of 32 residents reviewed during the initial pool. Findings: Review of the facility's policy titled, Call Light/Call Pager Systems, with a revision date of 09/09/2022, revealed the following, in part: Policy: The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Resident #2 Review of Resident #2's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction and Hemiplegia and Hemiparesis Following Nontraumatic Intracerebral Hemorrhage Affecting Left Non-Dominant Side. Review of Resident #2's current Care Plan revealed the resident was at risk for falls. Interventions included to keep the call bell within reach when in room and answer promptly. On 09/30/2024 at 10:19 a.m., an observation was made of Resident #2 in her room. She was sitting in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide privacy to residents when receiving assistance with personal care for 1 (#52) of 4 (#15, #52, #70, and #140) residents reviewed for ADL (Activities of Daily Living) care. The facility failed to ensure the privacy curtain was pulled between Resident #52 and his roommate prior to staff initiating assistance to change his soiled brief and bed linens. Findings: Review of the facility's policy titled, Dignity, with a revision date of 02/2021, revealed the following, in part: Policy Statement: Each Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of Resident #52's Clinical Record revealed the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days and indicated the duration for 1 (#2) of 3 (#1, #2, and #3) sampled residents. Findings: Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #2's June 2024 Physician's Orders revealed an order written on 06/03/2024 for Temazepam 7.5 mg tablet, one tablet by mouth as needed for Insomnia at night. Further review revealed the PRN medication had no stop date or duration. Review of Resident #2's June 2024 Medication Administration Record (MAR) revealed Temazepam 7.5 mg tablet by mouth as needed for Insomnia at night was started on 06/03/2024. Further review revealed the PRN medication had no stop date or duration. On 06/20/2024 at 10:07 a.m., an interview was conducted with S2DON. He reviewed Resident #2's June 2024 MAR and Physician Orders. He confirmed Temazepam was a psychotropic medication and was ordered PRN for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to maintain a safe, functional, and sanitary environment. The facility failed to ensure: 1. There was a process in place to report and track maintenance concerns and commodes were maintained for 2 (#33 and #45) of 26 (#1, #3, #4, #10, #13, #14, #15, #16, #17, #27, #33, #35, #38, #42, #43, #44, #45, #46, #50, #57, #62, #64, #66, #69, #76, and #80) residents reviewed for environment in the initial pool. 2. Bedrails were clean and sanitized for 1 (Room B) out of 9 rooms reviewed for environment in the initial pool. Findings: 1. Resident #33 Review of Resident #33's MDS with an ARD of 08/02/2023 revealed he had a BIMS of 15, which indicated he was cognitively intact. Resident #45 Review of Resident #45's MDS with an ARD of 08/02/2023 revealed he had a BIMS of 15, which indicated he was cognitively intact. Review of the Maintenance Log from 09/21/2023 through 10/03/2023 revealed no entry related to Resident #33 and Resident #45's commode in Room A. An observation was made of the bathroom in Room A on 10/02/2023 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to ensure grievances were reported to the grievance official for 1 (#1) of 3 (#1, #4, and #35) residents reviewed for grievances. Findings: Review of the facility's policy titled, Resident Care Grievance Policy revealed the following, in part: Policy: Grievances/complaints are to be submitted to the Administrator who is named as the Grievance Official or their designee Review of Resident #1's MDS with an ARD of 07/05/2023 revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of the Facility's Grievance Log from April 2023 through September 2023 revealed no entries for Resident #1. An interview was conducted with Resident #1 on 10/02/2023 at 10:35 a.m. Resident #1 stated her pink purse became missing about two months ago. She stated she reported it to S19CNA and S20TD. An interview was conducted with S19CNA on 10/04/2023 at 11:55 a.m. She stated Resident #1 reported a missing purse to her two months ago. She stated she figured the purse got mixed with her laundry. She stated she went to the laundry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure appropriate alternatives were attempted prior to installing bed or side rails for 1 of 1 (#10) residents reviewed for bed or side rails out of 26 residents screened for the initial pool. Findings: Review of the facility's Bed/Side Rails policy revealed, in part: Purpose: To ensure a bed is appropriate for the resident and that if bed rails are required, they are utilized, installed, and maintained properly. 1.5 Policy: Appropriate alternative methods to aid a resident in functional bed mobility must be attempted prior to installing a side or bed rail. Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Palsy, Intellectual Disabilities, Lack of Coordination, and Contractures of the Right and Left Hands. Review of Resident #10's Quarterly MDS with an ARD of 07/19/2023 revealed he was unable to complete the BIMS assessment due to an inability to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure 1 (#4) of 5 (#1, #2, #3, #4, and #5) residents reviewed for Resident Assessment had an accurate MDS that reflected the resident's wound care status. Findings: Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus, Polyneuropathy, and Disorder of the Skin and Subcutaneous Tissue. Review of Resident #4's current Physician Orders revealed beginning on 05/21/2023, an order for DTI (Deep Tissue Injury) Right Heel: Paint with betadine three times weekly until resolved. Review of Resident #4's Quarterly MDS with an ARD of 06/07/2023 revealed the following questions and answers related to Section M - Skin Conditions: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage: G. Unstageable - Deep Tissue Injury 1. Number of unstageable pressure injuries…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.