Inspection Reports for
Heritage Manor of Baton Rouge II

The facility failed to maintain accurate medication administration records for 3 sampled residents, with discrepancies between the Narcotic Log Sheets and Medication Administration Records (MAR). This posed potential minimal harm to some residents.

The facility failed to ensure staff wore proper PPE while providing perineal care to a resident on Enhanced Barrier Precautions. An observation confirmed a staff member did not wear a gown as required, and the Director of Nursing acknowledged the protocol.

The facility failed to timely report an allegation of neglect and elopement of Resident #3, failed to develop and implement a comprehensive care plan addressing Resident #3's protective order and open EPS case, failed to ensure adequate supervision to prevent elopement, and failed to maintain a safe, clean, and functional environment in several areas of the facility. The Immediate Jeopardy was removed after the facility implemented corrective actions including staff training, audits, and quality assurance measures.

The facility failed to properly coordinate PASARR Level II assessments into resident care plans for multiple residents, failed to provide trauma-informed care for a resident with PTSD, had a medication error rate exceeding 5%, failed to properly store medications with loose pills found on a medication cart, and failed to maintain proper infection control practices during perineal care.

The complaint investigation was substantiated. Resident #1 was found with injuries after an altercation with Resident #2 on 10/11/2024. Multiple staff interviews and video footage confirmed the incident. The facility implemented corrective actions prior to the State Agency's investigation.

The facility failed to protect Resident #1 from physical abuse by Resident #2, resulting in scratches to Resident #1's arm and face. The facility took immediate corrective actions including separation of residents, medical treatment, and implementation of a plan of correction.

The investigation was complaint-driven, focusing on documentation and notification failures related to resident transfers and discharges, and timely completion of resident assessments. The Ombudsman was not notified timely of a discharge, and required documentation was missing for emergency transfers.

The facility failed to document the reason for discharge of a resident transferred to a hospital, did not provide timely notification of discharge to the Ombudsman, and failed to complete and transmit a reentry MDS assessment within required timeframes for another resident.

The facility was found deficient in implementing physician's orders for tube feedings, posting nurse staffing data daily, and maintaining proper infection prevention practices including PPE use during incontinent care.

The facility failed to ensure proper referral for PASRR Level II evaluations for residents with new mental health diagnoses, maintain medication storage standards including removal of expired and unlabeled medications, ensure food safety by discarding moldy and unlabeled food items, and uphold infection control protocols during medication administration.

The complaint investigation substantiated that Resident #1 sexually abused Resident #2 on 10/11/2023. Staff failed to report the incident to administration immediately, delaying intervention and placing residents at risk. Resident #1 was arrested and charged with felony sexual battery. The facility implemented corrective actions including removal of Resident #1, staff training, and monitoring.

The facility failed to protect residents from sexual abuse by Resident #1, who had a history of sexually inappropriate behaviors. Resident #1 touched Resident #2 inappropriately on 10/11/2023, and staff failed to report the incident to administration immediately, resulting in an immediate jeopardy situation. Corrective actions were implemented prior to the State Agency's investigation.

The complaint investigation substantiated neglect for Residents #2 and #6 due to failure to provide incontinent care for 8 hours on 08/01/2023. The facility also failed to report the neglect allegation to the state survey agency within the required timeframe.

The facility failed to protect residents #2 and #6 from neglect by not providing incontinent care from 6:00 a.m. to 2:00 p.m. on 08/01/2023. Additionally, the facility failed to timely report the neglect allegations to the state survey agency within 24 hours.

The facility failed to ensure Resident #2 received Klonopin as ordered due to an erroneous discontinuation of the medication from 04/18/2023 to 05/15/2023. Corrective actions were implemented prior to the State Agency's investigation, resulting in a Past Noncompliance citation.

The facility was found deficient in multiple areas including failure to treat residents with dignity by serving meals on disposable dishware for some residents, failure to document and resolve grievances properly, failure to update and facilitate resident participation in care plans, inadequate assistance with activities of daily living such as nail care, improper respiratory care with expired or unlabeled oxygen tubing, and presence of expired medication in storage.