Inspection Reports for
Landmark of Baton Rouge
9105 OXFORD PLACE DRIVE, BATON ROUGE, LA, 70809
Back to Facility Profile7 Reports
Inspection Report — Dec 2, 2025
CMS
Date: Dec 2, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards regarding the maintenance of accurate medical records and documentation of incidents, specifically reviewing a witnessed fall involving Resident #1.
Findings
The facility failed to maintain accurate records and ensure nursing staff accurately documented a witnessed fall involving Resident #1. The responsible nurse did not report or document the fall incident, nor file an incident report, which was confirmed by interviews and record reviews.
Deficiencies (1)
Failed to maintain accurate records and document a witnessed fall involving Resident #1.
Report Facts
Residents sampled: 3
Residents affected: 1
BIMS score: 3
Incident date: Nov 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 LPNR | Licensed Practical Nurse | Responsible for Resident #1's care on the morning of the fall; failed to document and report the incident |
| S3 CNA | Certified Nursing Assistant | Assisted in the witnessed fall incident and called for assistance |
| S4 CNA | Certified Nursing Assistant | Assisted in returning Resident #1 to bed using 3-person lift |
| S1 DON | Director of Nursing | Interviewed and confirmed failure to document and report the fall incident |
| S5 FNP | Family Nurse Practitioner | Notified about Resident #1's condition after the fall |
Inspection Report — Feb 26, 2025
Annual Inspection CMS
Date: Feb 26, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements, including accuracy of resident assessments, PASRR screening, infection prevention and control, and proper coding of resident data.
Findings
The facility failed to ensure accurate coding of resident assessments for PASRR, pressure ulcers, and discharge status for several residents. Additionally, the facility did not maintain proper infection prevention and control practices, including improper catheter care and catheter bags being placed on the floor.
Deficiencies (3)
Failure to ensure the MDS assessment accurately reflected the resident's status for 3 residents (#5, #60, and #122), including PASRR coding, pressure ulcer coding, and discharge coding.
Failure to ensure a resident with mental disorders had an accurate Pre-admission Screening for PASRR for 1 resident (#118).
Failure to implement and maintain an infection prevention and control program, including improper hand hygiene and catheter care for Resident #55 and catheter bag placement for Resident #60.
Report Facts
Residents sampled: 27
Residents reviewed for PASRR: 5
Residents affected: 3
Residents affected: 1
Residents observed with catheters: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3MDS | Responsible for completing resident's MDS assessments; confirmed inaccurate coding for Resident #5 | |
| S2DON | Reviewed Resident #5 and #60 information and confirmed inaccurate coding; confirmed catheter bags should be kept off the floor | |
| S11CRP | Reviewed Resident #5 information and confirmed inaccurate coding | |
| S5MDS | Reviewed Resident #60's physician orders and MDS; confirmed inaccurate coding for pressure ulcers | |
| S4MDS | Reviewed Resident #122's discharge documentation and confirmed inaccurate coding | |
| S8WCN | Confirmed Resident #60 had an unhealed stage 4 pressure ulcer and catheter bag was lying on the floor | |
| S12SSD | Responsible for submitting resident review forms for Level II evaluation; confirmed Resident #118 PASRR was inaccurately coded | |
| S1ADM | Reviewed Resident #118 Level I PASRR and confirmed inaccurate coding and failure to resubmit resident review form | |
| S9CNA | Observed performing catheter care for Resident #55; failed to change gloves appropriately | |
| S10CNA | Confirmed Resident #60's catheter bag was lying on the floor and should not have been |
Inspection Report — Mar 26, 2024
Complaint Investigation CMS
Date: Mar 26, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding resident rights, activities of daily living care, accident prevention, and staffing adequacy at Landmark of Baton Rouge nursing home.
Complaint Details
The complaint investigation revealed substantiated issues including failure to honor resident bathing preferences, missed scheduled baths, delayed incontinence care with a call light wait time of two hours, inadequate supervision during Hoyer lift transfers, and insufficient CNA staffing leading to unmet resident care needs.
Findings
The facility failed to promote resident self-determination regarding bathing preferences and bed mobility, failed to provide scheduled baths and timely incontinence care, failed to ensure adequate supervision during Hoyer lift transfers, and failed to maintain sufficient certified nursing assistant staffing to meet resident care needs.
Deficiencies (4)
Failed to promote and facilitate resident self-determination through support of resident choice regarding type of bath and timing of getting back in bed.
Failed to ensure residents unable to carry out activities of daily living received necessary services to maintain good hygiene, including missed baths and delayed incontinence care.
Failed to ensure adequate supervision to prevent accidents during Hoyer Lift transfers requiring two staff members.
Failed to provide enough nursing staff daily to meet the needs of residents, resulting in missed baths, delayed care, and inability to complete assigned tasks.
Report Facts
Residents affected: 4
Residents reviewed: 6
Staffing rating: 1
Total residents: 53
CNA staffing: 1
Call light wait time: 120
Bath days missed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S14 CNA | Certified Nursing Assistant | Responsible for Resident #R4's bath and reported staffing shortages impacting care |
| S7 WC | Ward Clerk | Confirmed Resident #R4's call light was on for two hours before assistance |
| S6 CNA | Certified Nursing Assistant | Confirmed missed baths and staffing shortages on Hall C |
| S9 CNA | Certified Nursing Assistant | Reported staffing shortages and missed baths on Hall B |
| S16 CNA | Certified Nursing Assistant | Only CNA assigned to Hall B without shower aide, unable to bring residents to shower room |
| S2 DON | Director of Nursing | Confirmed staffing shortages and care deficiencies |
| S13 CNA | Certified Nursing Assistant | Observed transferring Resident #R6 alone with Hoyer lift, contrary to policy |
Inspection Report — Jan 23, 2024
Routine CMS
Date: Jan 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, pharmaceutical services, medication administration, labeling, and infection prevention and control.
Findings
The facility failed to implement comprehensive person-centered care plans, ensure specialty consult appointments were scheduled as ordered, provide accurate medication dispensing and administration, label and discard insulin pens properly, and maintain infection prevention practices including sanitizing insulin pen stoppers prior to use.
Deficiencies (4)
Failed to implement a comprehensive person-centered care plan and ensure specialty consult appointments were scheduled as ordered for Resident #35.
Failed to provide pharmaceutical services assuring accurate dispensing and administration of medications; observed medication error with insulin administration for Resident #22.
Failed to ensure drugs and biologicals were labeled properly, including insulin pens not labeled with date opened and not discarded after 28 days for multiple residents.
Failed to provide and implement an infection prevention and control program; nursing staff did not sanitize insulin pen stoppers prior to attaching needles for Residents #22 and #34.
Report Facts
Residents reviewed: 25
Residents observed for medication administration: 5
Residents affected: 1
Residents affected: 1
Medication carts observed: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2LPN | Licensed Practical Nurse | Involved in medication administration error and failure to sanitize insulin pen stoppers |
| S1DON | Director of Nursing | Confirmed expectations for scheduling appointments, medication administration, labeling, and infection control practices |
| S3LPN | Licensed Practical Nurse | Confirmed insulin pens were not labeled with open dates and not discarded after 28 days |
| S4LPN | Licensed Practical Nurse | Confirmed insulin pens were not labeled with open dates and not discarded after 28 days |
| S5NP | Nurse Practitioner | Confirmed medication orders and importance of verifying correct insulin |
| S7NP | Nurse Practitioner | Confirmed expectations for scheduling specialty consult appointments |
| S8WC | Scheduling Coordinator | Confirmed lack of scheduled specialty appointments for Resident #35 |
Inspection Report — Sep 14, 2023
Complaint Investigation CMS
Date: Sep 14, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding failure to provide timely toileting assistance to Resident #1 when requested.
Complaint Details
Complaint was made by Resident #1's family member regarding delayed toileting assistance after call light was activated at 5:30 p.m. Staff failed to respond timely; CNA turned off call light and did not return. Interviews with CNA, LPN, DON, and Administrator confirmed the incident and acknowledged failure to assist Resident #1 as requested.
Findings
The facility failed to ensure Resident #1 was provided toileting assistance when requested, despite the resident using the call light and family complaints. Interviews confirmed staff turned off the call light and did not return to assist the resident, resulting in minimal harm or potential for actual harm.
Deficiencies (1)
Failure to ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason, specifically failure to provide toileting assistance to Resident #1 when requested.
Report Facts
Residents reviewed for ADLs: 5
Residents affected: 1
Call light wait time: 15
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 CNA | Certified Nursing Assistant | Named in failure to assist Resident #1 with toileting after call light activation |
| S3 LPN | Licensed Practical Nurse | Interviewed regarding Resident #1's toileting needs and call light use |
| S2 DON | Director of Nursing | Interviewed about staff responsibilities during meal times and toileting assistance |
| S1 ADM | Administrator | Interviewed regarding expectations for staff response to Resident #1's call light and toileting assistance |
Inspection Report — Feb 16, 2023
Routine CMS
Date: Feb 16, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on staff compliance with hand hygiene and glove use during incontinent care.
Findings
The facility failed to implement appropriate infection control practices by not ensuring staff changed gloves and performed hand hygiene properly during incontinent care for one resident out of six reviewed. Observations and interviews confirmed staff did not use hand sanitizer or change gloves as required.
Deficiencies (1)
Failure to ensure staff appropriately changed gloves and performed hand hygiene during incontinent care for Resident #32.
Report Facts
Residents reviewed for incontinent care: 6
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (S11CNA) | Observed failing to perform hand hygiene and change gloves appropriately during incontinent care | |
| Director of Nursing (S1DON) | Interviewed and confirmed expectations for hand hygiene and glove use |
Inspection Report — Feb 16, 2023
Annual Inspection CMS
Date: Feb 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, activities of daily living assistance, and infection control practices at Landmark of Baton Rouge nursing home.
Findings
The facility was found deficient in ensuring consistent documentation of residents' code status, timely development of baseline care plans, provision of necessary assistance with activities of daily living including nail care, and implementation of proper infection prevention and control practices.
Deficiencies (4)
Failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#30) of 32 residents reviewed.
Failed to develop and implement a baseline care plan for 1 (#304) resident within 48 hours of admission.
Failed to provide fingernail care for Resident #32 who was unable to carry out activities of daily living.
Failed to implement appropriate infection control practices by failing to ensure staff appropriately changed gloves and performed hand hygiene for Resident #32 during incontinent care.
Report Facts
Residents reviewed for advanced directives: 32
Residents reviewed for care plans: 32
Residents reviewed for activities of daily living: 25
Residents reviewed for infection control: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7LPN | Interviewed regarding Resident #30's code status discrepancies | |
| S11CNA | Interviewed regarding Resident #30's code status and Resident #32's nail care and infection control practices | |
| S10LPN | Interviewed regarding admission procedures and care plan entry for Resident #30 | |
| S6LPN | Interviewed regarding verification of Resident #30's advance directives | |
| S9LPN | Interviewed regarding code status verification procedures | |
| S1DON | Interviewed confirming expectations for code status documentation, care planning, nail care, and infection control | |
| S3RN | Interviewed confirming lack of baseline care plan for Resident #304 | |
| S2CM | Presented baseline care plan started on 02/14/2023 for Resident #304 | |
| S4RN | Interviewed regarding nail care responsibilities and awareness of Resident #32's needs | |
| S12CNA | Interviewed regarding reporting Resident #32's nail care request | |
| S5RN | Interviewed regarding receipt of nail care requests for Resident #32 |
Viewing
Loading inspection reports...
