Inspection Reports for
The Guest House Care Center
10145 FLORIDA BLVD, BATON ROUGE, LA, 70815
Back to Facility Profile8 Reports
Inspection Report — Apr 30, 2025
Routine CMS
Date: Apr 30, 2025
Visit Reason
Routine inspection of The Guest House Care Center to assess compliance with healthcare regulations including resident care, medication administration, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to treat residents with dignity during care, inaccurate resident assessments, incomplete care plans, missed medication administrations, improper infection control practices, unlabeled medications, incomplete documentation, and a non-functioning call light system for a resident.
Deficiencies (10)
F 0550: The facility failed to ensure staff greeted Resident #54 and explained care during incontinence care, violating the resident's right to dignity.
F 0641: The facility failed to accurately code Resident #93's discharge location, incorrectly listing it as a hospital instead of home/community.
F 0656: The facility failed to implement a person-centered care plan by not performing blood sugar monitoring and medication side effect monitoring for Residents #12, #24, #46, and #70 as ordered.
F 0677: The facility failed to provide fingernail care for Resident #198, leaving nails dirty despite scheduled baths.
F 0686: The facility failed to provide appropriate pressure ulcer care by not floating Resident #197's heels while in bed as ordered.
F 0755: The facility failed to ensure medications were administered for Residents #12, #24, #46, and #70 on 04/27/2025 at 8:00 p.m., with no documentation of administration.
F 0761: The facility failed to label insulin pens and eye drops with opened dates on medication carts, including Resident #82's insulin pen and medications for Residents #30 and #147.
F 0842: The facility failed to ensure S16LPN completed and accurately documented interventions on the Medication Administration Record for Resident #94 on 02/22/2025.
F 0880: The facility failed to maintain infection control by staff not performing hand hygiene and proper glove use during incontinence care for 11 residents observed.
F 0919: The facility failed to ensure a functioning call system for Resident #26, with the call light not working from 04/27/2025 and staff failing to notify maintenance timely.
Report Facts
Residents affected: 11
Residents reviewed for medication administration: 4
Residents reviewed for ADLs: 3
Residents reviewed for pressure ulcers: 2
Residents reviewed for environment: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S14CNA | Certified Nursing Assistant | Named in dignity and infection control deficiencies related to Resident #54 and multiple residents during incontinence care |
| S18LPN | Licensed Practical Nurse | Named in medication administration deficiency for not administering medications on 04/27/2025 |
| S2DON | Director of Nursing | Interviewed regarding expectations for assessments, medication administration, infection control, and call light system |
| S16LPN | Licensed Practical Nurse | Failed to document interventions on Medication Administration Record for Resident #94 |
| S9CNA | Certified Nursing Assistant | Observed and interviewed regarding improper hand hygiene during incontinence care |
| S6CNA | Certified Nursing Assistant | Observed and interviewed regarding improper hand hygiene during incontinence care |
| S13CNA | Certified Nursing Assistant | Observed and interviewed regarding improper hand hygiene during incontinence care |
| S10MS | Maintenance Supervisor | Interviewed regarding call light system maintenance and notification |
| S1ADM | Administrator | Interviewed regarding call light system notification and response |
Inspection Report — Jan 7, 2025
Annual Inspection CMS
Date: Jan 7, 2025
Visit Reason
The inspection was conducted to assess compliance with care planning requirements and to evaluate the facility's adherence to physician orders and care plan updates for residents.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for residents, including failure to follow physician orders for wheelchair brake extenders and failure to update care plans for activities of daily living dependency and fall interventions after incidents.
Deficiencies (2)
F 0656: The facility failed to ensure Resident #2's wheelchair had brake extenders as ordered and failed to develop a comprehensive care plan for Resident #3's ADL dependency deficits.
F 0657: The facility failed to revise Resident #3's care plan to include interventions for falls after an unwitnessed fall on 12/31/2024.
Report Facts
Residents reviewed: 3
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2ADON | Confirmed brake extenders were not in place as ordered for Resident #2. | |
| S1DON | Confirmed staff were expected to follow physician orders and care plan requirements. | |
| S3MDS | Responsible for care plans and confirmed failures to care plan ADL dependencies and fall interventions. |
Inspection Report — Sep 10, 2024
CMS
Date: Sep 10, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration at the nursing facility.
Findings
The facility failed to ensure that Resident #1's Oxycodone medication was documented in the Medication Administration Record (MAR) at the time of administration, resulting in documentation errors by a licensed practical nurse.
Deficiencies (1)
F 0658: The facility failed to ensure Resident #1's Oxycodone was documented in the MAR at the time of administration. Documentation errors were identified for multiple doses signed off late by the licensed practical nurse.
Report Facts
Medication doses with documentation errors: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Named in documentation errors for Oxycodone medication administration |
| S2DON | Director of Nursing | Interviewed regarding expectations for medication documentation |
Inspection Report — Jul 31, 2024
Complaint Investigation CMS
Date: Jul 31, 2024
Visit Reason
The investigation was conducted due to a complaint regarding the facility's failure to promptly notify the physician of a significant change in condition for Resident #1, resulting in delayed treatment and hospitalization.
Complaint Details
The complaint investigation substantiated that the facility failed to notify the medical provider immediately of Resident #1's significant change in condition on 07/13/2024, resulting in delayed treatment and an immediate jeopardy to resident health and safety.
Findings
The facility failed to ensure nursing staff communicated a significant change in condition to the resident's physician for Resident #1, leading to an immediate jeopardy situation. Resident #1 experienced a left proximal femur fracture that was not promptly reported, causing delayed treatment and prolonged pain. The facility implemented corrective actions and achieved substantial compliance by 07/23/2024.
Deficiencies (2)
F580: The facility failed to immediately notify the resident's physician of a significant change in condition for Resident #1, resulting in delayed diagnosis and treatment of a left proximal femur fracture.
F0684: The facility failed to provide appropriate treatment and care according to orders and professional standards when nursing staff did not recognize, monitor, intervene, or document Resident #1's significant change in condition, causing delayed treatment and hospitalization.
Report Facts
Date of significant change: Jul 13, 2024
Date of x-ray order: Jul 15, 2024
Date of surgery: Jul 16, 2024
BIMS score: 3
BIMS score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Failed to notify medical provider of Resident #1's significant change in condition on 07/13/2024. |
| S5LPN | Licensed Practical Nurse | Administered Tylenol and confirmed failure to report Resident #1's change in condition to provider. |
| S6NP | Nurse Practitioner | Assessed Resident #1 on 07/15/2024 and confirmed delayed notification caused decline in condition. |
| S2DON | Director of Nursing | Confirmed failure to notify medical provider immediately and delayed treatment for Resident #1. |
| S10ADON | Assistant Director of Nursing | Conducted incident investigation and confirmed significant change in condition was not reported timely. |
Inspection Report — Apr 18, 2024
Complaint Investigation CMS
Date: Apr 18, 2024
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to honor a resident's advance directive and inaccurate documentation of medical records.
Complaint Details
The complaint investigation found substantiated issues regarding failure to honor a resident's advance directive and inaccurate medical record documentation.
Findings
The facility failed to honor a resident's do-not-resuscitate (DNR) advance directive by initiating CPR contrary to the directive. Additionally, the facility inaccurately documented the resident's mood status on the Medication Administration Record.
Deficiencies (2)
F 0578: The facility failed to ensure a resident's advance directive was honored for 1 of 3 residents reviewed. CPR was initiated despite a documented DNR order.
F 0842: The facility failed to maintain accurately documented medical records for 1 of 3 residents reviewed. Nursing staff inaccurately documented the resident's mood as sad when no signs were observed.
Report Facts
Residents reviewed for advanced directives: 3
Residents affected: Described as 'Many' for the advance directive deficiency
Residents reviewed for medical records accuracy: 3
Residents affected: Described as 'Few' for the medical record documentation deficiency
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Nurse who initiated CPR on Resident #1 | |
| S4LPN | Nurse who found Resident #1 unresponsive | |
| S1DON | Director of Nursing who confirmed CPR initiation and inaccurate documentation | |
| S2LPN | Nurse who documented sadness inaccurately on Medication Administration Record |
Inspection Report — Apr 11, 2024
Complaint Investigation CMS
Date: Apr 11, 2024
Visit Reason
The inspection was conducted based on complaints regarding resident care, including failure to promote resident self-determination, mail delivery issues, grievance resolution, timely incontinence care, bed rail safety assessments, and nurse aide competency.
Complaint Details
This complaint investigation was triggered by allegations of failure to assist Resident #28 out of bed as requested, failure to deliver mail on Saturdays, failure to resolve grievances, failure to provide timely incontinence care, failure to assess and obtain consent for bed rails, and failure to ensure nurse aide competency. The findings substantiated these issues with minimal harm or potential for actual harm to residents.
Findings
The facility was found deficient in multiple areas including failure to assist Resident #28 out of bed as requested, failure to deliver mail on Saturdays, failure to resolve grievances timely, failure to provide timely incontinence care for Residents #75 and #88, failure to assess and obtain consent for bed rails for Resident #41, and failure to ensure nurse aide competency for Residents #28 and #34.
Deficiencies (7)
F 0561: The facility failed to promote resident self-determination by not assisting Resident #28 out of bed at her requested time of 10:00 a.m.
F 0576: The facility failed to ensure residents received mail on Saturdays, holding mail until Monday for 4 residents.
F 0585: The facility failed to initiate and resolve grievances for Resident #11, including failure to report a missing phone charger to administration.
F 0677: The facility failed to provide timely incontinence care for Residents #75 and #88, resulting in residents being soiled and strong urine odor in rooms.
F 0700: The facility failed to assess risk of entrapment and obtain informed consent for bed rails prior to installation for Resident #41.
F 0726: The facility failed to ensure nurse aide S5CNA was competent in skills and techniques necessary to care for residents, including transfers and bed baths for Residents #28 and #34.
F 0835: The facility failed to administer resources effectively to ensure S5CNA was competent in skills and techniques for residents' care.
Report Facts
Residents reviewed for mail delivery: 17
Residents affected by mail delivery issue: 4
Residents reviewed for grievances: 2
Residents affected by grievance issue: 1
Residents reviewed for ADLs: 5
Residents affected by incontinence care issue: 2
Residents identified with bed rails: 2
Residents affected by nurse aide competency issue: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5CNA | Certified Nursing Assistant | Named in findings for failure to assist Resident #28 out of bed and incompetency in providing care to Residents #28 and #34. |
| S4LPN | Licensed Practical Nurse | Informed S5CNA to get assistance for Resident #28 but confirmed Resident #28 was not assisted out of bed. |
| S3CNAS | Certified Nursing Assistant Supervisor | Responsible for CNA orientation and competency sign-off; signed off S5CNA's orientation despite lack of observed competency. |
| S2DON | Director of Nursing | Confirmed failures in resident care and CNA competency oversight. |
| S1ADM | Administrator | Reviewed CNA orientation checklist and confirmed expectations for CNA competency and computer access. |
Inspection Report — Aug 30, 2023
Complaint Investigation CMS
Date: Aug 30, 2023
Visit Reason
The inspection was conducted following a complaint alleging sexual abuse involving two residents at the facility.
Complaint Details
The complaint was substantiated. Resident #2 was witnessed kissing and touching Resident #1 without consent. Resident #2 admitted to the behavior and was placed on 1:1 supervision and referred for mental health evaluation.
Findings
The facility failed to protect Resident #1 from inappropriate sexual contact by Resident #2. Corrective actions were implemented prior to the State Agency's investigation, and staff received training on abuse policies and procedures.
Deficiencies (1)
F 0600: The facility failed to protect Resident #1 from sexual abuse by Resident #2, who kissed and touched Resident #1 without consent. Resident #1 was cognitively impaired and unable to consent, while Resident #2 was cognitively intact and aware of his actions.
Report Facts
Residents affected: 1
Residents reviewed for abuse: 9
Inspection Report — May 17, 2023
CMS
Date: May 17, 2023
Visit Reason
The inspection was conducted to assess compliance with pre-admission screening and resident review program requirements, specifically regarding referrals for PASRR Level II evaluations for residents with identified mental health diagnoses.
Findings
The facility failed to ensure that Resident #15, who had multiple mental health diagnoses, was referred for a required PASRR Level II evaluation. Interviews with staff confirmed that no Level II PASRR referral was submitted or on file for this resident.
Deficiencies (1)
F 0644: The facility failed to coordinate assessments with the pre-admission screening and resident review program by not referring Resident #15 for a required PASRR Level II evaluation despite multiple mental health diagnoses.
Report Facts
Residents reviewed for PASRR: 4
Residents with mental health diagnosis not referred: 1
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