THE OAKS
For profit - Limited Liability company
125 Beds
Independent
Data: November 2025
Trust Grade
40/100
#166 of 264 in LA
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
The Oaks has a Trust Grade of D, indicating below average performance with several concerns. It ranks #166 out of 264 nursing homes in Louisiana, placing it in the bottom half of facilities in the state, and #7 out of 10 in Ouachita County, meaning only three local options are better. The facility's trend is worsening, with issues increasing from 4 in 2024 to 7 in 2025. Staffing is a concern, with a turnover rate of 61%, significantly higher than the state average of 47%, suggesting instability among staff. While there is average RN coverage, which is important for catching potential problems, the facility has reported serious incidents, including cases of verbal abuse between residents and failures to inform residents about psychotropic medications, raising significant red flags about resident safety and care. Overall, families should weigh the concerning aspects against any positive factors when considering this nursing home.
- Trust Score
- D
- In Louisiana
- #166/264
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $27,005 in fines. Higher than 68% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 38%
Needs review
4 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 7 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 61%
15pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $27,005
Below median ($33,413)
Moderate penalties - review what triggered them
Staff turnover is elevated (61%)
13 points above Louisiana average of 48%
The Ugly 17 deficiencies on record
1 actual harm
Jun 2025
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1
Review of the medical record for Resident #1 revealed an admission date of 03/11/2008 with a diagnosis of spastic qu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1
Review of the medical record for Resident #1 revealed an admission date of 03/11/2008 with a diagnosis of spastic quadriplegic cerebral palsy.
Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated that Resident #15 was cognitively intact. Additionally, the MDS documented that Resident #15 was dependent on staff for all activities of daily living.
On 06/09/2025 at 9:00 a.m. and 4:50 p.m. revealed Resident #1 was observed in her customized wheelchair with her legs dangling with no support noted to her lower extremities.
On 06/10/2025 at 10:10 a.m. and 1:00 p.m. revealed Resident #1 was observed in her customized wheelchair with her legs dangling with no support noted to her lower extremities.
Review of the current plan of care revealed no documentation related to Resident #1's non-compliance with the use of the wheelchair leg rests.
On 06/11/2025 at 11:10 a.m., an interview with S2DON was conducted. S2DON was informed that Resident #1's non-compliance with the use of the wheelchair leg rests was not documented in the plan of care.
Based on observations, record reviews, and interviews the facility failed to develop a comprehensive person-centered care plan that addressed declined care or services for 2 (#30, #1) of 25 (#57, #218, #13, #365, #19, #38, #49, #217, #58, #46, #32, #25, #24, #30, #215, #59, #47, #17, #36, #29, #16, #27, #216, #14, #43, #1, #51, #56, #40, #26, #42, #50, #11, #9, #23, #5, #6) total sampled residents.
Findings:
Resident #30
Review of the medical record for Resident #30 revealed an admission date of 03/19/2024 with diagnoses that included Parkinson's disease with dyskinesia, hypertension, repeated falls, and major depressive disorder.
Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that Resident #30 was cognitively intact. Additionally, the MDS documented that Resident #30 required set-up or clean-up assistance with meals.
Review of the Physician's Orders documented Resident #30's diet as pureed texture with nectar liquids.
Review of the dietary note dated 02/26/2025 documented that Resident #30 was non-compliant with the ordered diet.
Review of the current plan of care revealed no documentation related to Resident #30's non-compliance with the ordered diet.
On 06/11/2025 at 11:10 a.m., an interview with S2Director of Nursing (DON) was conducted. S2DON was informed that Resident #30's non-compliance with the ordered diet was not documented in the plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure it had sufficient nursing staff with appropriate competenc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure it had sufficient nursing staff with appropriate competencies and skills to provide nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident by having staff fail to follow physician orders for 1 (#38) of 6 (#19, #38, #25, #30, #43, #5) residents reviewed for unnecessary medications. The failed practice was also evidenced by staff not implementing physician orders in a timely manner for 1 (#23) of 1 (#23) residents investigated for the use of antibiotics.
Findings:
Resident #38
Review of the medical record for Resident #38 revealed she was admitted on [DATE] with a diagnosis of diabetes. Review of the June 2025 physician orders revealed a finger stick blood sugar (FSBS) check was to be performed 4 times daily and the physician was to be notified if a blood sugar was greater than 301. Review of the blood sugar monitoring revealed the following blood sugar results of 301 or greater.
On 06/02/2025 at 6:00 a.m., Resident #38`s FSBS was 436.
On 06/03/2025 at 4:00 p.m., Resident #38`s FSBS was 323.
On 06/04/2025 at 4:00 p.m., Resident #38`s FSBS was 323.
Review of the progress notes revealed there was no documentation that the physician was notified of Resident #38's above high blood sugar levels.
On 06/10/2025 at 11:10 a.m., interview with S2Director of Nursing (DON) confirmed there was no documentation the physician was notified of Resident #38`s high blood sugar results.
Resident #23
Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Parkinson`s disease, schizoaffective disorder, vascular dementia, and urinary tract infection. Review of the most recent Minimum Data Set assessment dated [DATE] revealed Resident #23 had a Brief Interview of Mental Status score of 12 which indicated moderate cognitive impairment.
Review of lab results revealed a urinalysis pathogen report dated 06/04/2025 which indicated Resident #23 had pathogens present in her urine. An order for Doxycycline 100 milligrams (mg) was written and signed by a physician on 06/04/2025 at the bottom of the report. S6Licensed Practical Nurse (LPN) signed the order on 06/06/2025.
Review of the June 2025 Medication Administration Record (MAR) revealed the first dose of Doxycycline 100 mg was given on 06/07/2025 at 8:00 a.m.
On 06/10/2025 at 3:34 p.m., S2DON was informed an order for Doxycycline 100 mg was written by a physician on 06/04/2025 at 6:06 p.m. for Resident #23 and the order was signed by S6LPN on 06/06/2025 at 9:00 a.m. S2DON was also informed the first dose of the Doxycycline was administered on 06/07/2025 at 8:00 a.m.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to obtain laboratory examinations as ordered by the physic...
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Based on interviews and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to obtain laboratory examinations as ordered by the physician for 1 (#43) of 6 (#19, #38, #25, #30, #43, #5) sampled residents reviewed for unnecessary medications.
Findings:
Resident #43
Review of the medical record for Resident #43 revealed he had an admission date of 04/02/2025 with diagnoses which included diabetes, depression, gastroenteritis and colitis.
Review of the physician orders revealed the resident received Lexapro 10 milligrams (mg) daily, Lipitor 40 mg daily, and Novolog insulin three times daily and as needed based on blood sugar levels. Review of the physician orders revealed an order dated 05/03/2025 for the following lab work: Lipids to be drawn annually; Complete Metabolic Panel (CMP) and Complete Blood Count (CBC) to be drawn every 6 months; and a Hemoglobin A1C to be obtained every 3 months. Further review revealed a physician order dated 04/30/2025 to obtain a CBC, CMP, and Thyroid Stimulating Hormone (TSH) level.
Review of the medical record revealed there was no evidence the above lab work had been obtained as ordered.
On 06/11/2025 at 7:45a.m., an interview with S2Director of Nursing (DON) confirmed the lab work was not obtained as ordered.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews the facility failed to ensure residents were informed of the risks, benefits and side ef...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews the facility failed to ensure residents were informed of the risks, benefits and side effects of psychotropic medications for 6 (#19, #38, #25, #30, #43, #5) of 6 (#19, #38, #25, #30, #43, #5) residents reviewed for unnecessary medications.
Findings:
Resident #38
Review of the medical record for Resident #38 revealed she had an admission date of 03/01/2024 with diagnoses which included anxiety and depression.
Review of the physician orders revealed Resident #38 received the psychotropic medications Alprazolam 0.25 milligrams (mg) daily and Olanzapine 5 mg daily for the treatment of anxiety and Sertraline 50 mg daily for the treatment of depression.
Review of the medical record revealed there was no documentation of a consent for the psychotropic medications.
Resident #25
Review of the medical record for Resident #25 revealed she was admitted on [DATE] with diagnosis which included depression.
Review of the physician orders revealed Resident #25 received Trintellix 20 mg daily and Seroquel 150 mg daily for the treatment of depression.
Review of the medical record revealed there was no documentation of a consent for the psychotropic medications.
Resident #30
Review of the medical record for Resident #30 revealed she was admitted on [DATE] with diagnosis which included depression.
Review of the physician orders revealed Resident #30 received Escitalopram 10 mg daily for the treatment of depression.
Review of the medical record revealed there was no documentation for the consent for the psychotropic medication.
Resident #43
Review of the medical record for Resident #43 revealed he was admitted on [DATE] with diagnosis which included depression.
Review of the physician orders revealed Resident #43 received Lexapro 10 mg daily for the treatment of depression.
Review of the medical record revealed there was no documentation for the consent for the psychotropic medication.
Resident 5
Review of the medical record for Resident #5 revealed an admission date of 02/12/2025 with diagnoses which included anxiety and depression.
Review of the June 2025 physician's orders for Resident #5 dated 02/12/2025 revealed an order for Alprazolam 0.5 mg to be given every 8 hours as needed for anxiety. Further review of the orders revealed an order dated 02/20/2025 for Lexapro 10 mg to be administered every day.
Review of the medical record revealed there was no documented evidence of a psychotropic medication consent obtained prior to administering the medications.
Resident #19
Review of the medical record for Resident #19 revealed she had an admission date of 03/21/2023 with diagnoses of generalized anxiety disorder and depression.
Review of the physician orders revealed Resident #19 received the following psychotropic medications: Rexulti 2mg by mouth daily, Cymbalta 30mg by mouth twice daily, and Buspar 10mg 1 by mouth every 8 hours as needed.
Review of the medical record revealed there was no documentation of a consent for the psychotropic medications.
On 06/10/2025 at 11:10a.m., interview with S2Director of Nurses (DON) confirmed the facility had not obtained consents for any resident that currently received psychotropic medications.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5:
Review of the medical record for sampled Resident #5 revealed an admission date of 02/12/2025. Resident #5 had diag...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5:
Review of the medical record for sampled Resident #5 revealed an admission date of 02/12/2025. Resident #5 had diagnoses which included shortness of breath, diabetes mellitus, heart disease, anxiety and depression.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had a BIMS score of 15, which indicated the Resident had intact cognition for daily decision making.
Review of the June 2025 physician's orders dated 02/12/2025 revealed an order for Alprazolam (Xanax) 0.5 mg to be given every 8 hours as needed for anxiety. Review of the June 2025 MAR revealed Resident #5 received Xanax 0.5 mg prn on 06/07/2025.
Review of the April 2025 and May 2025 Consultant Pharmacist DRR revealed the following recommendation for Xanax .5 mg every 8 hours prn: provide specific duration/stop date for the prn psychotropic medication due to the medication is limited to 14 days and requires the prescriber to evaluate the Resident. Further review revealed there was no documentation the facility addressed the above recommendation.
On 06/11/2025 at 2:45 p.m. an interview with S2DON confirmed the above recommendation from the pharmacist consultant was not addressed in a timely manner and Resident #5 continued to receive the Xanax 0.5 mg every 8 hours prn.
Based on record reviews and interviews, the facility failed to ensure residents that received psychotropic drugs had a gradual dose reductions, and residents that had orders for psychotropic medications as needed (PRN) were not subjected to chemical restraints for 2 (#5, #19) of 6 (#5, #19, #25, #30, #38, #43) residents reviewed for unnecessary medications. The facility failed to ensure:
1). A resident that was on psychotropic drugs received gradual dose reductions (#19); and
2). PRN orders for psychotropic drugs were limited to 14 days (#5, #19).
Findings:
Resident #19:
Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including vascular dementia, generalized anxiety disorder, and chronic obstructive pulmonary disease.
Record review of the significant change Minimal Data Set (MDS) dated [DATE] revealed Resident #19 had a brief mental status score (BIMS) of 15 which indicated she had no cognitive impairment. Further review revealed she required partial - moderate assistance for most activities of daily living (ADL).
Review of Resident #19's June 2025 physician orders revealed an order for Buspar 10 milligrams (mg) every 8 hours as needed (PRN). Review of the Resident's June 2025 Medication Administration Record (MAR) revealed documentation the resident had received Buspar 10mg on 06/04/2025 and 06/10/2025.
Review of the Pharmaceutical Consultant Report dated 01/13/2025 revealed the following recommendation for Buspar 10mg q 8 hours prn: a PRN psychotropic is limited to 14 days and required the prescriber to evaluate the Resident prior to extending the order. If extending the order, document the rationale for the extended time period in the medical record and indicated a specific duration.
Review of May 2025 Consultant Pharmacist Drug Regimen Review (DRR) revealed the following recommendation for Buspar 10mg every 8 hours prn: provide specific duration/stop date for the PRN psychotropic medication due to the medication is limited to 14 days and required the prescriber to evaluate the resident. Further review revealed there was no documentation the facility addressed the above recommendation.
On 06/11/2025 at 2:45p.m., S2Director of Nursing (DON) confirmed the above recommendation from the consultant pharmacist was not addressed in a timely manner and Resident #19 continued to receive the Buspar 10mg every 8 hours prn. S2DON also confirmed, the facility failed to ensure that Resident #19 received a gradual dose reduction for the past year per the consultant pharmacist recommendations.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure adequate supervision and assistive devices t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure adequate supervision and assistive devices to prevent accidents were in place for 1 (#23) of 5 (#5, #11, #14, #23, #30) residents investigated for accidents. The failed practice was evidenced by Resident #23 being identified as an unsafe smoker, she was observed smoking without a smoking apron, and was observed having smoking articles in her possession without direct supervision.
Findings:
Review of the facility`s Smoking Policy, with a revision date of June 2024, revealed in part the following:
4. All unsafe smoking residents shall wear a smoking apron while smoking in the designated smoking area.
15. Smoking articles for residents without independent smoking privileges:
a. Residents without independent smoking privileges may not have or keep any types of smoking articles except when they are under direct supervision.
Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Parkinson`s disease, schizoaffective disorder, vascular dementia, and urinary tract infection. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment.
Review of the facility`s most recent smoking assessment for Resident #23 dated 01/28/2025 revealed Resident #23 had 1) insufficient fine motor skills needed to securely hold a cigarette, 2) burns to skin, clothing, or furniture, and 3) dropped ashes on herself. The assessment also revealed the following concerns: unable to light a cigarette safely, unable to hold a cigarette safely, unable to extinguish a cigarette safely, and unable to use an ashtray to extinguish a cigarette.
On 06/09/2025 at 10:15 a.m., observation revealed Resident #23 got 2 cigarettes and a lighter from S3Licensed Practical Nurse (LPN) as she was administering medications to other residents. Resident #23 was observed rolling herself in her a wheelchair toward the smoking room with the 2 cigarettes and lighter without direct supervision.
On 06/09/2025 at 10:40 a.m., Resident #23 was observed smoking a cigarette in the designated smoking room. S4Certified Nursing Assistant (CNA) reported Resident #23 only required supervision to smoke. Resident #23 was not wearing a smoking apron.
On 06/10/2025 at 1:53 p.m., an interview with S2 Director of Nursing (DON) confirmed Resident #23 was an unsafe smoker. S2DON confirmed Resident #23 should wear an apron when smoking and should be supervised when she had possession of smoking articles. S2DON was informed Resident #23 was given a cigarette lighter and 2 cigarettes by S3LPN while in the hallway. S2DON was also informed Resident #23 rolled herself in her wheelchair down the hallway with the lighter and she had cigarettes in her possession without direct supervision.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on record review and interviews the facility failed to ensure the Infection Preventionist, who was responsible for the facility's infection prevention and control program, had completed speciali...
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Based on record review and interviews the facility failed to ensure the Infection Preventionist, who was responsible for the facility's infection prevention and control program, had completed specialized training in infection prevention and control.
Findings:
Review of the facility's Infection Control Records revealed there was no documented evidence the Infection Preventionist, S5Licensed Practical Nurse (LPN), had completed specialized training in infection prevention and control.
On 06/10/2025 at 9:50 a.m. an interview with S5LPN revealed she did not have any specialized training in infection prevention.
On 06/10/2025 at 1:10 p.m. an interview with S2Director of Nursing (DON) confirmed the facility did not have a nurse that had received specialized training in infection prevention.
Jun 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure a resident who is unable to carry out activit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 (#3 and #37) of 2 (#3 and #37) residents reviewed for Activities of Daily Living (ADL) care. The facility [NAME] to 1) ensure resident hand mitts were changed when dirty and 2) ensure that resident finger and toenails were kept clean and trimmed.
Findings:
Resident #3
Review of the Nail Management Policy and Procedure revealed the nail management was the regular care of the toenails and fingernails to promote cleanliness and skin integrity of tissues to prevent infection and injury from scratching by fingernails or pressure of shoes on toenails. Further review of the policy revealed that debris was to be removed from under the nails with an orange stick while soaking and to trim the nails with a clipper, straight across for the toenails, rounded for the fingernails.
Review of resident's record revealed he was admitted to the facility on [DATE] with diagnoses including a personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, severe vascular dementia, primary open-angle glaucoma, cerebral palsy and a Stage 4 pressure ulcer of the right hip.
On 06/11/24 at 11:14 a.m., an observation revealed resident #3 was lying in his bed. Further observation revealed resident #3's right hand had a mitt covering the hand. The outside the mitt (palm area) had a large area of an old, dried reddish-brown colored stain that covered approximately two thirds of the palm of the mitt.
On 06/11/2024 at approximately 11:40 a.m., S3Licensed Practical Nurse (LPN) was notified of the findings regarding the stain on resident #3's hand mitt. After observing the mitt with S3LPN, she confirmed that the hand mitt was unclean and needed to be changed. She then reapplied the dirty hand mitt.
On 06/11/2024 at 4:35 p.m., S2Director of Nursing (DON) was notified of the observation of resident #3's right hand mitt being stained. During an observation with S2DON, she removed the dirty hand mitt from resident #3's hand and a visual inspection of resident's right hand revealed the skin on the inside palm of the hand was crusty and dirty. Further observation revealed the resident's fingernails were jagged, long, and untrimmed. S2DON confirmed that resident #3's mitt needed to be changed, the resident's fingernails needed to be trimmed and cleaned, and resident #3's hand needed to be cleaned.
On 06/12/2024 at approximately 4:00 p.m., S1Director of Operations was notified of the findings regarding resident #3.
Resident #37
Review of resident #37's record revealed he was admitted to the facility on [DATE] with diagnosed including Parkinson's disease, vascular dementia, and shortness of breath.
On 06/10/24 at 9:00 a.m., an observation revealed resident #37 lying in his bed. Further observation revealed the resident's toe nails to both feet were jagged and long.
06/11/2024 at approximately 4:20 p.m., S2DON was notified of the findings. After an observation with S2DON, she confirmed that resident #37's toe nails needed to be trimmed.
On 06/12/2024 at approximately 4:05 p.m., S1Director of Operations was notified of the findings regarding resident #37.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (#3) of 3 (#3, #30, and #60) residents investigated for pressure ulcers. The facility failed to prevent pressure ulcers from developing as evidenced by resident #3 having six unidentified pressure ulcers.
Findings:
Record review revealed resident#3 was admitted to the facility on [DATE] with diagnoses including a personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, severe vascular dementia, primary open-angle glaucoma, cerebral palsy and a Stage 4 pressure ulcer of the right hip.
During wound care on 06/12/2024 at 8:45 a.m. with S5Wound Care Nurse (WCN) and S6WCN, a visual inspection of resident #3's right feet revealed one deep tissue injury to the posterior area of the great toe, the lateral part of the great toe, and heel. Observation of the left foot revealed there was one deep tissue injury to the lateral part of the 5th toe, posterior part of the lateral 5th toe, and left ankle. There was pillow underneath the resident's legs, however, the tips of his feet toughing and in direct contact with the bed mattress. S5WCN and S6WCN confirmed they were unaware of resident #3's six deep tissues to his feet. Further inspection of the resident's feet revealed there was an area between resident #3's toes on the left foot that had a thick, flaky, and crusty buildup of peeling skin. S5WCN and S6WCN both confirmed that confirmed that resident #3's toes needed to be cleaned.
On 06/12/2024 at 9:58 a.m., an interview with resident #3's floor nurse, confirmed she too, was not aware of resident #3's six newly identified pressure ulcers to the feet as no one had reported them to her.
On 06/12/2024 at 10:15 a.m., during an interview with S1Director of Operations, he was notified of the findings regarding resident #3's six newly identified pressure ulcers.
During an interview on 06/12/2024 at approximately 3:45 p.m., S2Director of Nursing was notified of the findings regarding resident #3's six newly identified pressure ulcers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to provide adequate supervision to prevent accidents a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to provide adequate supervision to prevent accidents and ensure the resident's environment remained free of hazards for 1 (#62) of 3 (#31, #37, #62) residents reviewed for safe smoking.
Findings:
Review of the facility's Smoking Policy with a revision date of 2023 revealed in, part:
This facility shall establish and maintain safe resident smoking practices, to incorporate smoking safely and take into account non-smoking residents.
Policy Interpretation and Implementation:
All residents shall wear a smoking apron while smoking in the designated smoking area.
Any smoking related privileges, restrictions, and concerns (for example, the need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.
The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision.
Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.
Smoking articles for residents without independent smoking privileges:
Resident's without independent smoking privileges may not have or keep any types of smoking articles except when they are under direct supervision.
Smoking shall not be permitted in bed. Violation will result in immediate discharge from the facility.
Violation of all or any portion of the smoking policy will result in immediate discharges from the facility.
Review of the medical record for resident #62 revealed an admission date of 02/16/2024 with diagnoses of type 2 diabetes mellitus, cellulitis of right lower limb, alcohol dependence, noncompliance with medical treatment, repeated falls, hypertension, and nicotine dependence.
Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 11,which indicated moderate cognitive impairment.
Review of resident #62's current care plan revealed, a potential for injury related to smoking cigarettes as an unsafe smoker.
Inventions: Resident will have a designated smoking area; Resident was assessed to be an unsafe smoker on 04/23/2024.
Further review of the care plan revealed 05/06/2024 resident found smoking in his room;
06/01/2024 resident caught smoking in his room; 06/06/2024 had care plan meeting with the resident's sister and ombudsman regarding the resident smoking in his room.
Review of the Smoking Evaluation Tool dated 06/01/2024 revealed the interdisciplinary team determined resident #62 was an unsafe smoker due to intermittent confusion and smoking in his room.
Review of the nurse note dated 04/09/2024 at 10:44 p.m. revealed resident #62 used the call light for assistance and when this nurse walked in the room it had a strong cigarette odor. The nurse asked the resident if he had been smoking in his room and the resident #62 stated that it was just a little butt. The nurse then instructed the resident he cannot smoke in his room.
Further review of the nurses notes dated 06/01/2024 at 9:13 a.m. revealed the CNA (Certified Nurse Aide) notified the nurse that resident #62 was sitting in his room smoking a cigarette. This nurse notified the resident this was unacceptable and took the cigarette.
Review of the nurse note dated 06/10/2024 at 9:36 p.m. revealed resident #62 is being monitored in the smoking area tonight. Resident #62 was seen putting ashes in the trash can instead of the designated smoking container. The nurse informed the resident to only put ashes in the cigarette container due to the risk and danger with putting them in the trash can. Resident #62 stated he put water in the trash can so it was ok. The nurse moved the trash can and placed designated smoking container close to resident.
Observation on 06/10/24 at 09:23 a.m. revealed resident #62 was sitting in a wheel chair in the designated smoking area. Resident #24 was seen lighting a cigarette for resident #62. Further observation revealed resident #62 smoked the cigarette and was placing the cigarette ashes and butt in a garbage can that contained a plastic liner and trash. Resident #62 was not wearing a smoking apron and no staff were present to monitor residents.
Interview on 06/11/2024 at 1:40 p.m. with S4LPN (Licensed Practical Nurse) confirmed that resident #62 was observed smoking last night (06/10/2024) and placing ashes in a garbage can. S4LPN stated that she has observed resident #62 on multiple occasions smoking in his room. S4LPN confirmed resident #62 was an unsafe smoker.
Interview on 06/12/2024 at 8:15 a.m. with S1Director of Operations confirmed that resident #62 had been identified as an unsafe smoker and that staff had observed the resident smoking in his room on multiple occasions. S1Director of Operations also confirmed that the facility did not follow their policy and procedure in regards to the facility's smoking policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of five percent or greater by ...
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Based on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of five percent or greater by committing 2 errors out 32 opportunities for an error rate of 6.25%.
Findings:
Observation of the medication pass on 06/11/2024 at 7:24 a.m. for resident #267 revealed the following medication errors.
Citracal-D3 200mg (milligrams) - 250 Unit, (Calcium Citrate supplement) 1 tablet daily. This medication was not administered.
Review of the June 2024 physician orders for resident #267 revealed an order for Citracal-D3, 200mg-250Unit, 1 tablet daily at 8:00 a.m.
Interview on 06/12/2024 at 10:40 a.m. with S3Licensed Practical Nurse (LPN) confirmed that she did not administer the medication Citracal-D3 to resident #267. S3LPN stated that this medication was not available.
Observation of the medication pass for resident #267 on 06/11/2024 at 7:24 a.m. revealed S3LPN administered the angiotensin-converting enzyme inhibitor, Lisinopril, 20mg, 1 tablet.
Review of the June 2024 physician orders for resident #267 revealed an order for Lisinopril 10mg, one tablet daily.
Interview on 06/12/2024 at 12:55 p.m. with S3LPN confirmed that she administered Lisinopril 20mg tablet instead of Lisinopril 10mg. Further interview with S3LPN confirmed that the correct order was for Lisinopril 10mg daily.
Interview on 06/12/2024 at 1:50 p.m. with S2Director of Nursing (DON) confirmed that medications are to be administered as ordered. S2 DON was informed of medication errors at this time. S2DON confirmed that she was notified by S3LPN that she did not administer medication Citracal to resident #267 and that resident #267 should have been administer Lisinopril 10mg instead of 20mg.
Nov 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to protect the residents' right to be free from verbal ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to protect the residents' right to be free from verbal abuse and mental abuse for 2 (#3 and #5) of 4 (#1, #2, #3 and #5) residents reviewed for abuse; evidenced by resident #4 used sexually inappropriate language and gestures toward resident #3 and resident #5.
This deficient practice resulted in an actual harm for resident #5, who had moderate cognitive impairment, on 10/18/2023 at 1:15 p.m. when resident #4 made an inappropriate sexual comment and gesture to resident #5. This resulted in resident #5 becoming upset and crying. Resident #5 was assisted to her room and was consoled by staff. While being consoled by staff, Resident #5 remained upset and cried for approximatley10 minutes.
This deficient practice resulted in an actual harm for resident #3, who was cognitively intact, on 11/22/2023 at approximately 2:50 p.m. when resident #4 made an inappropriate sexual comment and gesture to resident #3. This resulted in resident #3 feeling uncomfortable and feeling afraid that resident #4 would return to her room. Staff consoled resident #3 until resident #4 was sent out to the hospital the same day. Resident #3 also received counselling from an outpatient counselor that came to the facility on [DATE].
Findings:
Review of facility's current Abuse and Neglect Prohibition Policy in part revealed:
Each Resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.
Fundamental information
Definitions:
Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish.
Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault.
Verbal abuse is defined as the use or oral, written or gestured language that willfully, includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.
Resident #4
Review of the medical record revealed resident #4 was admitted to the facility on [DATE], with a readmission date of 10/26/2023. Resident #4 had diagnoses that included metabolic encephalopathy, acute respiratory failure unspecified with hypoxia or hypercapnia, shortness of breath, type 2 diabetes mellitus, hypertension, Alzheimer's disease, altered mental status, anxiety, and vascular dementia with behavioral disturbances.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status of 11, which indicated the resident had moderate cognition for daily decision making. The MDS also documented that resident #4 required limited assistance of two person physical assist with transfers, supervision and set up, and limited assistance / one person physical assistance with dressing, toileting, personal hygiene, and bathing. The assessment also documented the resident was ambulatory with a walker, his gait was not steady, and he had no Range of Motion (ROM) impairment in the upper or lower extremities.
Review of the care plan for resident #4 revealed the resident had impaired cognition and short/long term memory loss related to diagnosis of dementia with behavioral disturbance. He also was care planned for alteration in mood states due to anxiety.
Resident #5
Review of the medical record for resident #5 revealed an admission date of 07/19/2023 with diagnoses that included the following: cerebral infarction, hemiplegia following cerebral infarction affecting right dominant side, essential hypertension, schizophrenia, unspecified convulsions, aphasia following cerebral infarction, and congestive heart failure.
Review of quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status of 11, which indicated the resident had moderate cognition for daily decision making. The 10/24/2023 assessment documented that resident #5 had impairment of ROM on one side upper and lower extremity, used a wheel chair for locomotion, and required partial/moderate assistance with Activities of Daily Living (ADLs) including transfers. The assessment also showed resident #5 was able to feed herself with set up and supervision.
Review of the care plan for resident #5 revealed Psychotropic medication use related behaviors with diagnoses of schizophrenia, depression, pseudobulbar affect.
Review of a Resident Incident Report dated 10/18/2023 at 1:15 p.m. revealed resident #5 was nonverbal but attempted to inform staff that a male resident (resident #4) grabbed himself and made an inappropriate comment while on the hallway that was unwitnessed.
On 11/28/2023 at 9:00 a.m. an interview with S4Registered Nurse (RN) reported that S3Certified Nursing Assistant (CNA) told her that resident #4 had grabbed his crotch in the dining room in front of resident #5 and told her to come get this big d---. S4RN reported that she did not witness the event and just documented what S3CNA told her.
On 11/28/2023 at 9:20 a.m. interview with S3CNA revealed she was monitoring the dining room on 10/18/2023 before lunch and she reported that resident #4 stood up and faced resident #5 and grabbed his privates and told her Come get this big d---. S3CNA reported resident #5 began to cry and propelled herself out of the dining room. S3CNA revealed she followed resident #5 and assisted her to her room. Further interview with S3CNA revealed she stayed with resident #5 and consoled her while she was still upset and she continued to cry for about 10 minutes after returning to her room.
On 11/28/2023 at 9:30 a.m. an observation and interview of resident #5 revealed she had expressive aphasia (difficulty speaking) and was not able to communicate verbally but was able to answer yes and no questions by shaking her head. Resident #5 revealed she understood what the surveyor was saying. Resident #5 nodded yes when asked if resident #4 had grabbed his privates and used sexually inappropriate language toward her in the dining room. The surveyor asked resident #5 if this upset her and made her cry, she nodded her head yes.
On 11/28/2023 at 1:20 p.m. interview with S4RN revealed she went and checked on resident #5 on 10/18/2023 after this incident and she was crying and upset. S4RN asked resident #5 what happened and she could not understand her because resident #5 was upset and crying. S4RN revealed resident #5 cried for about 10 minutes in her room.
Resident #3
Review of the medical record revealed resident #3 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, diabetes mellitus, and generalized anxiety disorder.
Review of quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status of 14, which indicated the resident had intact cognition for daily decision making. Further review of the 11/07/2023 assessment revealed resident #3 had ROM impairment on both lower extremities and she required substantial/maximal assistance with transfers, dressing, personal hygiene, toileting and bathing.
Review of the care plan revealed alteration in psychosocial wellbeing related to anxiety.
Review of the Resident Incident Report dated 11/22/2023 at 2:50 p.m. revealed resident #3 had a male resident (resident #4) enter her room and make a sexual comment while touching himself through his pants. He did not expose himself or touch the resident at any time. Resident #3 showed some increased anxiety.
On 11/27/2023 at 11:25 a.m. observation and interview with resident #3 revealed she was alert and oriented. Resident #3 reported about a week ago resident #4 came into her room and stood at the foot of her bed and said do you want to suck my d---, as he grabbed his privates. Resident #3 told him no and to leave. Resident #3 revealed she started yelling for someone to help her. Resident #3 revealed a guy from therapy department came to her room and she told him what happened. Then some nurses came to check on me and one of the nurses stayed with her. Resident #3 reported the incident made her feel uncomfortable and scared that he would come back into her room.
On 11/27/2023 at 12:05 p.m. an interview with S5Rehab Director revealed on 11/22/2023 while he was in the therapy department he heard a female screaming Help, Help, Help. S5Rehab Director revealed he and S6Physical Therapy Assistant (PTA) exited the therapy department and they noticed resident #4 exiting resident #3's room and walk back to his room. S5Rehab Director revealed he went into resident #3's room and she was upset and crying. Resident #3 reported that resident #4 had come into her room and asked her if she wanted to suck his d--- and she reported he grabbed his privates.
On 11/27/2023 at 2:20 p.m. interview with S2Director of Nursing (DON) revealed she received a call from S8MDS Nurse on 11/22/2023 around 3:55 p.m. about what had occurred between resident #3 and resident #4. S2DON reported she instructed S8MDS Nurse to notify the physician and to get resident #4 to a behavioral health unit as soon as possible.
On 11/27/2023 at 2:30 p.m. a telephone interview with S7RN revealed she was in the MDS office with S8MDS Nurse and S9Wound Care Nurse when S5Rehab Director informed them of the incident between resident #3 and resident #4. S7RN reported that she, S8MDS Nurse and S9Wound Care Nurse went to resident #3's room to check on her. S7RN reported that resident #3 was visibly still upset.
On 11/28/2023 at 2:18 p.m. interview with S9Wound Care Nurse revealed she stayed with resident #3 and comforted her until after resident #4 had been sent out to the hospital. S9Wound Care Nurse reported resident #3 revealed she was afraid he would come back to her room. S9Wound Care Nurse revealed she continued to comfort her and reassure her resident #4 would not be coming back to her room and that he would be going to the hospital.
Review of social worker noted dated 11/22/2023 at 6:11 p.m. revealed S10Social Worker went to check on resident #3 regarding the inappropriate comments and gestures that were made toward her by a male resident. She stated she was doing ok, just shocked about what had happened. During conversation social worker mentioned getting an outpatient counselor to come see her regarding what happened. Resident #3 said she would like that.
On 11/27/2023 at 3:00 p.m. an interview with S10Social Worker reported she contacted local counselor on 11/22/2023 to come to the facility to talk with resident #3 and the counselor came to the facility and talked with resident #3 in her room that same day.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the provider failed to ensure all allegations of verbal abuse / mental abuse was reported ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the provider failed to ensure all allegations of verbal abuse / mental abuse was reported immediately, but no later than 2 hours after the allegation is made, to the State Survey Agency in accordance with State laws. The facility failed to:
1) report an allegation of verbal abuse and mental abuse to the state agency for 1 (#5) of 4 (#1, #2, #3, and #5) residents reviewed for abuse; and
2) report an allegation of verbal and mental abuse to the state agency within 2 hours of becoming aware of the abuse within 2 hours of becoming aware of the abuse situation, for 1 (#3) of 4 (#1, #2. #3, and #5) residents reviewed for abuse.
Findings:
Review of facility's current Abuse and Neglect Prohibition Policy in part revealed:
Each Resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.
Fundamental information
Definitions:
Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish.
Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault.
Verbal abuse is defined as the use or oral, written or gestured language that willfully, includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.
Investigation
1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law.
2. The facility will report such allegations to the state, as per state regulation.
3. The facility will report all investigation findings to the state as per state regulations.
Resident #5
Review of the medical record for resident #5 revealed an admission date of 07/19/2023 with diagnoses that included the following: cerebral infarction, hemiplegia following cerebral infarction affecting right dominant side, essential hypertension, schizophrenia, unspecified convulsions, aphasia following cerebral infarction, and congestive heart failure.
Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 11, which indicated the resident had moderate cognition for daily decision making. The 10/24/2023 assessment documented that resident #5 had impairment of ROM on one side upper and lower extremity, used a wheel chair for locomotion, and required partial/moderate assistance with Activities of Daily Living (ADLs) including transfers.
Review of a Resident Incident Report dated 10/18/2023 at 1:15 p.m. revealed resident #5 was nonverbal but attempted to inform staff that a male resident (resident #4) grabbed himself and made an inappropriate comment while on the hallway that was unwitnessed.
On 11/27/2023 at 1:00 p.m. an interview with S1 Administrator confirmed he did not report to the State Survey Agency for this alleged allegation of abuse.
Resident #3
Review of the medical record revealed resident #3 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, diabetes mellitus, and generalized anxiety disorder.
Review of quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status of 14, which indicated the resident had intact cognition for daily decision making. Further review of the 11/07/2023 assessment revealed resident #3 had Range of Motion (ROM) impairment on both lower extremities and she required substantial/maximal assistance with transfers, dressing, personal hygiene, toileting and bathing.
Review of the Resident Incident Report dated 11/22/2023 at 2:50 p.m. revealed resident #3 had a male resident (resident #4) enter her room and make a sexual comment while touching himself through his pants. He did not expose himself or touch the resident at any time. Resident #3 showed some increased anxiety.
Review of the report sent into the State Survey Agency revealed the incident occurred on 11/22/2023 at 2:54 p.m. The report also indicated that the incident was discovered on 11/22/2023 at 2:54 p.m. The original notification to State Survey Agency was given via email on 11/23/2023 at 10:00 a.m. by S1Admininstrator.
On 11/27/2023 at 8:20 a.m. an interview with S1Administrator revealed he did have an incident report he was working on to turn into the state, but he had issues with his password and was not able access and input the data into the state program. S1Administrator reported he emailed the State Survey Agency Office the initial information of the incident on 11/23/2023 at 10:00 a.m., which was after the 2 hour time frame for reporting incidents of abuse.
Oct 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide a resident the right to participate in the de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide a resident the right to participate in the development and implementation of his or her person-centered plan of care for 1 (#1) of 5 (#1 - #5) sampled residents. The facility failed to inform resident #1 prior to rearranging the furniture in her room. Findings:
Observation of resident #1 on 10/09/2023 at 1:36 p.m. revealed the resident was ambulating with a walker down the hall to the activity room to play BINGO.
Review of the medical record for resident #1 revealed the resident was admitted on [DATE] with the following diagnoses, in part: anxiety disorder, major depression, hypertension, muscle spasm, syncope and collapse, falls, low back pain, insomnia, osteoarthritis, intervertebral disc degeneration, and pain.
Review of the significant change Minimum Data Set, dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact.
Review of the care plan revealed the resident was at risk for falls. Further review of the care plan revealed an intervention on 08/28/2023 of the following: bed moved against the wall for safety reasons. Further review revealed the resident moved own bed away from the wall and refused to leave the bed against the wall. The resident also removed the fall mat.
An interview with resident #1 on 10/05/2023 at 3:28 p.m. revealed that the facility moved her bed and she did not want the furniture rearranged.
An interview with S4Licensed Practical Nurse (LPN) on 10/09/2023 at 4:17 p.m. confirmed the resident's bed had been turned against the wall and the fall mat was at the bedside. S4LPN reported the resident did not want the furniture rearranged.
An interview with S3Certified Nursing Assistant (CNA) Supervisor on 10/10/2023 at 8:55 a.m. revealed S3CNA Supervisor moved resident #1's bed against the wall and placed a fall mat beside the bed. CNA Supervisor confirmed she rearranged the resident's furniture without the resident's permission and confirmed that the resident did not want her furniture rearranged.
An interview with S2Director of Nursing (DON) on 10/11/2023 at 9:50 a.m. confirmed the resident did not participate in the decision to rearrange her furniture as an approach to her falls. S2DON further confirmed the resident did not want her furniture rearranged.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure each resident received adequate supervision an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (#1) of 5 (#1 - #5) sampled residents. The facility failed to thoroughly investigate resident #1's falls and implement appropriate and new interventions following each fall. Findings:
Observation of resident #1 on 10/09/2023 at 1:36 p.m. revealed the resident was ambulating with a walker down the hall to the activity room to play BINGO.
Review of the medical record for resident #1 revealed the resident was admitted on [DATE] with the following diagnoses, in part: anxiety disorder, major depression, hypertension, muscle spasm, syncope and collapse, falls, low back pain, insomnia, osteoarthritis, intervertebral disc degeneration, fractured shaft of left radius and ulna (08/26/2023), and pain.
Review of the significant change Minimum Data Set, dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. The resident required one person extensive assistance with bed mobility, dressing and personal hygiene. The resident required two person limited assistance with transfers and toilet use. Further review revealed the resident's balance during transitions from seated to standing position was not steady and the resident was only able to stabilize with assistance. The resident was occasionally incontinent of bladder and continent of bowel.
Review of the Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls.
Review of the Resident Incident Report dated 08/25/2023 at 8:00 p.m. revealed: Resident bending over to pick up baby doll from the floor and lost balance.
Review of the nurses notes dated 08/25/2023 at 8:00 p.m. revealed: found resident on the floor beside bed, complains of generalized pain, new order to send to emergency room for evaluation, resident did state she bent down to pick up her baby and kept going, out to emergency room via stretcher, 140/54, 92, and 98% at room air.
Review of the care plan revealed the following intervention for this fall: instruct resident to call for assistance when picking up items out of reach.
Review of the Resident Incident Report dated 08/26/2023 at 4:00 p.m. revealed the resident stated she was attempting to move her nightstand without assistance when she fell and landed on her left arm. Skin tear to left upper arm. Immediate actions taken: head to toe assessment, range of motion assessed, pain to left arm noted, vital signs obtained, ambulance service called and resident transferred to hospital for further evaluation, skin cleansed, triple antibiotic ointment and dressing applied, 144/74, 85, 18, 97.5 , and pain scale 6.
Review of the care plan revealed the following intervention for this fall: fall mat at bedside.
Review of the Resident Incident Report dated 08/29/2023 at 1:47 a.m. revealed the resident attempted to transfer unassisted from the bed to the restroom. Call light in reach, non-compliant with usage. No apparent injury. 98.2, 91, 20, 127/85, no pain.
Review of the care plan revealed the following intervention for this fall: call for assistance with transfers.
Review of the Resident Incident Report dated 09/08/2023 at 5:00 p.m. revealed: upon entering the room, found resident on the floor in the bathroom underwear was pulled up yet pants were not, lying on her right side with head facing the bathroom doorway, small amount of blood noted to right hand for skin tear to knuckles, no other injuries were noted. Resident was very slow to respond to this nurse, did respond to sternal rub, new order noted to send to hospital for evaluation. Out 5:35 p.m. 189/86, 109, 20, 97.3, pupils are equal, round and reactive to light and accommodation.
Review of the care plan revealed the following intervention for this fall: call for assistance with toileting.
An interview on 10/11/2023 at 9:50 a.m. with S2Director of Nursing (DON) confirmed resident #1's falls were not thoroughly investigated. S2DON further confirmed that following the fall on 08/26/2023, the fall mat at the bedside was not an appropriate intervention. S2DON confirmed the facility did not implement new approaches following the resident's falls on 08/29/2023 and 09/08/2023.
Jul 2023
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure that maintenance services were provided to maintain a safe environment for 1 (#19) of 1 (#19) sampled residents investigated for envir...
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Based on observation and interview, the facility failed to ensure that maintenance services were provided to maintain a safe environment for 1 (#19) of 1 (#19) sampled residents investigated for environmental issues. The facility failed to ensure Resident #19's bathroom flooring surface was not broken.
On 07/10/23 09:53 a.m., an observation of resident #19's bathroom revealed there were circular patterns on the floor's surface that surround floor drain. Further observation revealed the areas that were not intact. Further observation revealed the areas on the floor were unevenly broken.
On 07/11/2023 at 1:50 p.m., S2 Maintenance Supervisor was notified of the findings regarding resident #19's bathroom flooring being unevenly broken around the floor drain. S2 Maintenance Supervisor confirmed that he had not checked the resident's bathroom for any type of environmental issues and he had missed it. He confirmed floor was in need of repair and was a potential accident hazard for staff and /or visitors.
On 07/12/2023 at 3:25 p.m., S1 Administrator was notified of the findings regarding the flooring in resident #19's bathroom being unevenly broken an in need of repair.
Jun 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident received adequate supervision and ass...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents by failing to implement interventions and by failing to monitor effectiveness and modify an intervention for 1 (#3) of 5 (#1, 2, 3, 4, 5) residents reviewed for falls.
Findings:
Resident #3
On 06/05/2023 at 07:45 a.m., Resident #3 was observed sitting in a wheelchair at the nursing station. She was alert but pleasantly confused. Resident #3 asked me what in the world are you doing here, with a smile on her face. I informed her I was there to be sure she and other residents were getting the help they needed.
On 06/06/2023 at 08:35 a.m., Resident #3 was observed sitting in a wheelchair in front of her bedside table as an employee was changing the linens on the bed. Resident #3 had an empty breakfast tray in front of her and appeared to be sleeping. Resident #3 was easily aroused and confirmed she was very sleepy and needed to get back in bed. The employee acknowledged she was about to help her get back to bed. Resident #3 reported she got very tired after she ate.
Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included arthritis, repeated falls, confusion and Alzheimer`s disease.
Review of most recent MDS (minimum data set) dated 04/04/2023 revealed Resident #3 had a BIMS (brief interview of mental status) score of 11 which indicated moderate cognitive impairment.
Review of Section G, (functional status), revealed Resident #3 needed staff to provide 1 person assistance for bed mobility, transfer between surfaces to or from: bed, chair, wheelchair, standing position, and for use of the toilet.
Review of A/I (accident/incident) reports revealed Resident #3 had 7 falls since admission on [DATE].
The seven accidents/incidents were falls that occurred on 04/01/2023, 04/02/2023, 04/13/2023, 04/16/2023, 04/28/2023, 05/26/2023, and 06/06/2023.
Review of falls:
The fall on 04/01/2023 revealed Resident #3 called for help after she fell on the floor attempting to go to the bathroom without calling for assistance. Further review of the report revealed Resident #3 was placed back to bed with bed in low position and call light within reach for the immediate action after the incident. The report recorded Resident #3 was disoriented and did not follow commands.
The fall on 04/01/2023 was not listed on the care plan.
The fall on 04/02/2023 revealed Resident #3 was found on floor in her room. Resident #3 reported she fell trying to go to the restroom.
An immediate intervention was for staff to make hourly rounds.
Record review revealed no documentation of hourly rounds conducted.
The fall on 04/13/2023 revealed Resident #3 was found lying on the safety mat at the bedside when she yelled for help
Record review revealed there was no documentation that an investigation was conducted.
The fall on 04/13/2023 was not listed on the care plan.
The fall on 04/16/2023 revealed Resident on floor in bathroom calling for help and the report indicated she went to the restroom without assistance.
The care plan listed nonskid socks as an intervention.
The fall on 04/28/2023 revealed Resident #3 was found on the floor at the bedside with a nose bleed.
A floor mat was listed as an intervention.
Review of physician orders revealed no orders written for Resident #3 to have nonskid socks, a bedside fall mat, or hourly observation by staff.
Review of nurse`s notes, MAR (medication administration record), TAR(treatment administration record) revealed no daily record of Resident #3 having nonskid socks, a bedside fall mat, or hourly observation by staff as directed by the care plan.
On 06/07/2023 at 10:35 am, an interview with S2 DON (director of nurses) was conducted in her office. S2 DON confirmed Resident #3`s care plan had not been updated with interventions for 4 of the 7 falls. S2 DON confirmed Resident #3 did not have a daily record to reflect nonskid socks were being worn, a safety mat was at the bedside, and hourly observations were conducted as directed as an intervention after a fall.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 17 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $27,005 in fines. Higher than 94% of Louisiana facilities, suggesting repeated compliance issues.
- • Grade D (40/100). Below average facility with significant concerns.
- • 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Oaks's CMS Rating?
CMS assigns THE OAKS an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is The Oaks Staffed?
CMS rates THE OAKS's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at The Oaks?
State health inspectors documented 17 deficiencies at THE OAKS during 2023 to 2025. These included: 1 that caused actual resident harm and 16 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Oaks?
THE OAKS is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 125 certified beds and approximately 64 residents (about 51% occupancy), it is a mid-sized facility located in MONROE, Louisiana.
How Does The Oaks Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, THE OAKS's overall rating (2 stars) is below the state average of 2.4, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting The Oaks?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is The Oaks Safe?
Based on CMS inspection data, THE OAKS has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Oaks Stick Around?
Staff turnover at THE OAKS is high. At 61%, the facility is 15 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was The Oaks Ever Fined?
THE OAKS has been fined $27,005 across 1 penalty action. This is below the Louisiana average of $33,349. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is The Oaks on Any Federal Watch List?
THE OAKS is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.