Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Landmark Of Baton Rouge during CMS and state inspections, most recent first.
Nursing staff failed to accurately document and report a witnessed fall involving a resident with severe cognitive impairment and total dependence for ADLs. The LPN and CNAs involved did not record the incident in the medical record or complete an incident report, contrary to facility policy, and administration only became aware after the resident's representative noticed injuries.
The facility failed to ensure accurate MDS assessments for three residents, leading to deficiencies in coding. A resident was not correctly coded for a serious mental illness, another had incomplete documentation for a stage 4 pressure ulcer, and a third was inaccurately coded for discharge status. These errors were confirmed by the MDS coordinators and the DON.
A facility failed to ensure an accurate PASRR for a resident with Bipolar Disorder. The resident's Level I PASRR was incorrectly completed, not reflecting the diagnosis of a serious mental illness. Despite the resident's preadmission records and care plan confirming the diagnosis, the facility did not submit the necessary documentation for a Level II evaluation, even after a request from the Office of Behavioral Health.
The facility failed to maintain proper infection control during catheter care for two residents. A CNA did not change gloves between tasks for one resident, and another resident's catheter bag was repeatedly found on the floor. Both issues were confirmed by staff, highlighting a breach in infection control protocols.
The facility failed to promote and facilitate resident self-determination for two residents. One resident was given bed baths instead of showers as per her family's wishes due to staffing issues. Another resident, who required a Hoyer Lift, was unable to choose when to get back in bed and was only given bed baths instead of being taken to the shower room as per her care plan.
The facility failed to ensure that two residents received scheduled baths and timely incontinence care. One resident did not receive baths on multiple scheduled days, and another resident waited two hours for incontinence care after initiating a call light. Staff interviews and clinical records confirmed these deficiencies.
The facility failed to provide sufficient CNA staff, resulting in inadequate care for residents. Multiple residents missed baths, experienced delays in incontinence care, and did not receive timely assistance with daily living activities due to the high workload and insufficient staffing. Interviews with staff and the DON confirmed the ongoing staffing issues.
A facility failed to provide adequate supervision during a Hoyer Lift transfer for a resident with Hemiplegia and Hemiparesis. Despite the resident's lifting plan requiring two staff members, a CNA independently performed the transfer, contrary to the facility's policy.
Failure to Document and Report Witnessed Fall
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one resident who experienced a witnessed fall. Specifically, nursing staff did not document the witnessed fall in the resident's medical record or complete an incident report as required by facility policy. The LPN responsible for the resident's care on the morning of the incident confirmed that, after being called for assistance, she and two CNAs manually lifted the resident from the floor back to bed but did not report or document the event, believing it was not a fall. As a result, there was no record of the incident in the nurses' notes, and administration was not notified at the time. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had a care plan indicating a high risk for falls and the need for total lift assistance. The incident only came to light after the resident's representative noticed bruising and discoloration, prompting further investigation. The DON later confirmed that the event should have been documented as a fall and that the required documentation and reporting were not completed by the staff involved.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for three residents, leading to deficiencies in coding. Resident #5 was not correctly coded for having a serious mental illness, despite documentation from a PASRR Level II evaluation indicating such a condition. The MDS coordinator, S3MDS, and the Director of Nursing, S2DON, confirmed the error upon review. This oversight indicates a lapse in accurately reflecting the resident's mental health status in the MDS assessment. Resident #60's MDS assessment was incomplete regarding pressure ulcers, as sections related to unhealed pressure ulcers were left blank. Despite physician orders and wound care documentation indicating a stage 4 pressure ulcer, the MDS did not reflect this condition. Both the wound care nurse, S8WCN, and the MDS coordinator, S5MDS, acknowledged the discrepancy. Additionally, Resident #122 was inaccurately coded for discharge status, with the MDS indicating a discharge to a hospital rather than the resident's home. This error was confirmed by S4MDS and S2DON, highlighting a failure to accurately document the resident's discharge location.
Inaccurate PASRR for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure an accurate Pre-admission Screening and Resident Review (PASRR) for a resident with a mental disorder. The resident, who was admitted with a diagnosis of Bipolar Disorder, had an inaccurately completed Level I PASRR that did not reflect this diagnosis. The admission Minimum Data Set (MDS) indicated that the resident was not considered for a Level II PASRR despite having a serious mental illness. The resident's preadmission records and care plan both confirmed the diagnosis of Bipolar Disorder, yet the Level I PASRR completed by a social worker at a local hospital incorrectly stated that the resident did not have a mental disorder that could lead to chronic disability. Interviews conducted during the investigation revealed that the facility was aware of the inaccurate coding on the Level I PASRR. The Office of Behavioral Health had requested additional documentation to correct the error, but the facility had not responded. The staff member responsible for submitting resident review forms for Level II evaluation confirmed that a resident review form had not been submitted as required. The facility administrator also acknowledged the error and the need for resubmission of the resident review form for a Level II evaluation, which had not been done.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and infection control techniques during catheter care for two residents. For Resident #55, a CNA was observed performing catheter care without changing gloves between tasks, including wiping stool from the resident's buttocks, emptying the catheter bag, and touching the bathroom door handle. This lack of glove change was confirmed by both the CNA and the Director of Nursing (DON), indicating a breach in infection control protocols. Additionally, Resident #60's catheter bag was repeatedly observed lying on the floor over several days, which was confirmed by both a wound care nurse and a CNA. The DON also acknowledged that catheter bags should not be placed on the floor, highlighting a failure to maintain a sanitary environment for residents with catheters. Both residents had a history of urinary tract infections, underscoring the importance of proper infection control measures to prevent further complications.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for two residents. Resident #2, who had diagnoses including Cerebral Infarction and Unspecified Dementia, was supposed to receive showers on specific days as per her family's wishes. However, due to staffing issues, she was given bed baths instead. The CNA assigned to her hall confirmed that she was unable to bring residents to the shower room when working alone, which led to the resident not receiving the type of bath she preferred. Resident #R4, who had diagnoses including Bilateral Primary Osteoarthritis of the Knee and Morbid Obesity, required a Hoyer Lift for transfers and had a care plan that included going to the shower room on Wednesdays. However, due to staffing shortages, she was only given bed baths. Additionally, she was unable to choose when to get back in bed because the CNA informed her that she would have to wait for the next shift. Both CNAs and the Director of Nursing confirmed that residents should be able to choose the type of bath they receive and when to get out of bed, but these choices were not facilitated due to staffing issues.
Failure to Provide Scheduled Baths and Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene. Resident #R4 did not receive scheduled baths on multiple occasions, as confirmed by interviews with the resident and staff. Resident #R4's bath days were Monday, Wednesday, and Friday, but there was no documentation of a bath being given from 03/21/2024 to 03/25/2024. Staff members were unsure of their responsibilities, leading to missed baths. Similarly, Resident #R5, who had severe cognitive impairment, did not receive a bath on his scheduled bath day, 03/23/2024, as confirmed by staff interviews and the resident's own account of not having had a bath in five days. The facility failed to provide documentation for Resident #R5's bath on the scheduled day, indicating a lapse in care and hygiene maintenance for both residents. Additionally, the facility failed to provide timely incontinence care for Resident #R4. On 03/22/2024, Resident #R4's call light was on for two hours before she received assistance with incontinence care after having a bowel movement. During this time, she made multiple calls to the facility from her cell phone, which were confirmed by her call log and the ward clerk. Staff interviews revealed that the CNA assigned to Resident #R4 was occupied with other duties and was unaware of the extended wait time. The LPN on duty also confirmed that a two-hour wait time for a call light was excessive and not in line with the facility's standard of a twenty-minute response time. The deficiencies highlight a systemic issue in the facility's ability to provide timely and adequate care for residents' hygiene needs. Both the failure to provide scheduled baths and the delayed response to incontinence care indicate lapses in staff coordination and adherence to care plans. These deficiencies were confirmed through multiple interviews with residents and staff, as well as a review of clinical records and care plans.
Insufficient CNA Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient certified nursing assistant (CNA) staff to meet the needs of residents, resulting in inadequate care for four out of six residents reviewed. The facility's PBJ Staffing Data Report for Fiscal Year 2024 Quarter 1 revealed a 1-star staffing rating. On multiple dates, the facility had only one CNA assigned to each hall, and in some instances, there was no shower aide available, leading to missed baths and delayed care for residents. For example, Resident #1, who required partial assistance with eating and was dependent on staff for bathing, did not receive a whirlpool bath on days when hospice did not bathe her. Resident #2, who was dependent on staff for toileting and bathing, often received bed baths instead of showers due to insufficient staff to assist with the shower gurney. Resident #R4, who required a Hoyer Lift for transfers, experienced significant delays in receiving incontinence care and missed baths due to short staffing. On one occasion, her call light was on for two hours before she received assistance after a bowel movement. Similarly, Resident #R5, who was always incontinent and dependent on staff for bathing, reported not having had a bath in five days. CNAs confirmed that they were unable to complete their tasks timely due to the high workload and insufficient staffing, leading to residents waiting longer than two hours for incontinence care and missing scheduled baths. Interviews with staff members revealed that the facility was consistently understaffed, with CNAs responsible for more residents than they could adequately care for. The Director of Nursing (DON) confirmed that there were not enough CNAs scheduled to care for the residents on multiple occasions, and the facility had lost four CNAs in the last two weeks due to the workload. The lack of sufficient staffing led to residents not receiving timely care, including missed baths, delayed incontinence care, and inadequate assistance with daily living activities.
Inadequate Supervision During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision during a Hoyer Lift transfer for a resident diagnosed with Hemiplegia and Hemiparesis following a cerebral infarction. The resident's lifting plan explicitly required the assistance of two staff members for Hoyer Lift transfers. However, an observation revealed that a CNA independently transferred the resident using the Hoyer Lift, contrary to the specified requirement. The CNA confirmed that she performed the transfer alone and acknowledged that two staff members should always be present during such transfers. Further interviews with other staff members, including the CNAS and the DON, corroborated that the facility's policy mandates the presence of two staff members during Hoyer Lift transfers to prevent accidents. The DON reviewed the resident's clinical record and confirmed the necessity of two staff members for the resident's transfers. Despite this policy, the observed transfer was conducted by a single CNA, indicating a lapse in adherence to the facility's safety protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baton Rouge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Manor Of Baton Rouge Ii | 0 mi | — | 5 | 0 |
| Jefferson Manor Nursing And Rehab Ctr, Llc | 0.7 mi | — | 4 | 0 |
| Ollie Steele Burden Manor | 1.6 mi | — | 10 | 0 |
| White Oak Post Acute Care | 1.6 mi | — | 9 | 0 |
| Center Point Health Care And Rehab | 1.8 mi | — | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.