Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Plantation Oaks Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Address Psychotropic Medication Gradual Dose Reduction: A resident with chronic respiratory failure, CHF, AFib, CVA, DM2 with neuropathy, repeated falls, schizoaffective disorder, and recurrent severe MDD had a BIMS score of 10 and was prescribed brexpiprazole 2 mg HS and sertraline 100 mg daily. A pharmacy consultant recommended review of the routine use of both psychotropic meds and requested a GDR or rationale for continued use, but the physician response remained blank and the DON acknowledged the recommendations had not been addressed timely.
A resident with cognitive intactness, chronic knee pain, and a history of right knee arthroplasty reported that PRN Tramadol was not relieving her bilateral knee pain and requested stronger medication. The RN notified the physician's office, but the resident did not receive a new pain medication order until several days later, despite repeated pain ratings as high as 9 and the care plan's direction to evaluate pain medication effectiveness.
Delayed Response to Call Light Assistance Requests: Staff failed to respond in a timely manner to a resident's call light for incontinence care and linen change. The resident had dx including CVA, weakness, reduced mobility, and needed assistance with personal care; the MDS showed moderate cognitive impairment and the care plan called for incontinence care as needed. The resident reported the bed was wet with urine, the surveyor observed the call light request, and no staff member came to assist. The ADON confirmed staff should have responded, and other residents also reported excessive wait times for call light response.
Infection Prevention Program Not Maintained: A resident with chronic respiratory failure and multiple other diagnoses had an oxygen concentrator observed without filters in place despite an order to clean the filter weekly. In addition, staff in the shower room used disinfectant without following the product’s required 10-minute sit time, and the LPN infection preventionist was unaware of the manufacturer’s instructions.
Unsafe Smoker Care Plan Not Followed: A resident with COPD, PVD, a BKA, dysphagia, and moderate cognitive impairment was identified in the care plan as an unsafe smoker and required a smoking apron. During observation in the designated smoking area, the resident was smoking without the apron in place, and a CNA stated the apron was not required even though the ADON later confirmed it was listed as an intervention.
The facility did not post the most recent state inspection results for resident review. While the annual survey results from October 2023 were displayed, the complaint survey results from July 2024 were missing. This was confirmed by the administrator.
The facility failed to maintain a clean and safe environment, as observed in several resident rooms and bathrooms, where air conditioner vents contained dirt, grime, and black substances. Additionally, feces and mold were found in a resident's bathroom, and the laundry room had mold and improperly stored cleaning supplies. These issues were confirmed by the facility's administrator.
A resident with a suprapubic urinary catheter was observed twice with his catheter bag exposed while in his wheelchair outside of his room, contrary to the facility's policy requiring catheter bags to be covered. The resident, who had no cognitive impairment, was admitted with multiple diagnoses. The DON confirmed the catheter bag should have been covered, indicating a failure to implement the care plan.
A facility failed to provide appropriate services and assistance to a resident with limited mobility, as observed when the resident was improperly positioned in a wheelchair with feet dangling. The resident, who has severe cognitive impairment and requires assistance with all ADLs, was not given adequate support to maintain or improve mobility, as confirmed by the DON.
A resident with a colostomy did not receive appropriate care due to the facility's failure to provide the correct size colostomy bags for over a week. The resident, who had no cognitive impairment, resorted to using a makeshift bag. The DON confirmed the unavailability of new colostomy bags, indicating a failure to follow the care plan.
The facility failed to assess two residents for entrapment risk from bed rails and did not obtain informed consent before installation. Both residents had severe cognitive impairments and required assist bars for bed mobility, but there was no documented evidence of risk assessment or consent. The DON confirmed these deficiencies.
The facility failed to maintain sufficient nursing staff with the necessary competencies and skills during weekends from April to June 2024. The PB&J Staffing Data Report highlighted extremely low staffing levels, confirmed by the Business Office Manager. Specific weekends in April, May, and June were identified as having insufficient staff, not meeting required staffing hours.
The facility did not post daily nurse staffing information in a visible area accessible to residents and visitors. The staffing data was found in a binder behind the nurses' station, as confirmed by the DON, which was not accessible to residents or visitors.
A pharmacist did not identify or report irregularities in the administration of Midodrine for a resident with chronic conditions. The medication was given outside prescribed parameters, despite the resident's systolic blood pressure being above the limit. This oversight was confirmed by the DON.
A resident with multiple health conditions was administered Midodrine Hydrochloride outside of prescribed parameters, despite instructions to hold the medication if systolic blood pressure exceeded 120. The Director of Nursing confirmed the medication was improperly administered on several occasions.
The facility failed to follow professional standards for food preparation by using hot water to thaw frozen sausage. A dietary staff member confirmed the use of hot water, which was against USDA guidelines that recommend thawing in the refrigerator, cold water, or microwave. The facility administrator acknowledged that this method should not have been used.
A resident with multiple health conditions was physically abused by a CNA, who bent the resident's finger and foot and slapped them in the chest. The incident was witnessed by other staff but not reported immediately, allowing the CNA to continue working. The facility failed to follow its abuse policy and did not initiate monitoring or interviews to prevent further abuse.
A resident with multiple health issues was physically abused by a CNA, witnessed by another CNA and an LPN, but the incident was not reported to administration or law enforcement in a timely manner. The facility's policy required immediate reporting and suspension of the accused employee, but these procedures were not followed, and the CNA continued to work additional shifts before being terminated.
Failure to Address Psychotropic Medication Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure that a resident remained free from chemical restraints imposed for discipline or convenience and not required to treat medical symptoms, and failed to ensure that a resident prescribed psychotropic drugs received a gradual dose reduction unless clinically contraindicated. Resident #7 had diagnoses including chronic respiratory failure, chronic systolic congestive heart failure, paroxysmal atrial fibrillation, cerebral infarction, type 2 diabetes mellitus with diabetic polyneuropathy, repeated falls, other schizoaffective disorder, and major depressive disorder, recurrent, severe without psychotic features. The Annual MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment for daily decision making. The resident’s electronic orders showed brexpiprazole 2 mg at bedtime for other schizoaffective disorder and sertraline 100 mg daily for major depressive disorder. The pharmaceutical consultant’s psychoactive gradual dose reduction report recommended evaluation of the routine use of Rexulti 2 mg nightly and Zoloft 100 mg daily and asked for a dose reduction or a rationale for continued use. The report was signed by the DON and noted as sent to the provider for response, but the physician response section remained blank as of the survey date, indicating the pharmacist’s recommendations had not been addressed timely.
Delay in Addressing Resident's Unrelieved Pain
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with a history of Alzheimer's disease, vascular dementia, type 2 diabetes with diabetic neuropathy, aftercare following right knee joint replacement surgery, and pain in an unspecified knee. The resident's Quarterly MDS showed a BIMS score of 15, indicating she was cognitively intact, and the facility's pain risk assessment identified her as high risk for pain. Her care plan documented chronic pain related to primary generalized osteoarthritis and right knee arthroplasty and directed staff to evaluate the effectiveness of pain medication, including compliance, symptom relief, dosing schedules, resident satisfaction, and impact on function and cognition. The resident reported that she had undergone right knee surgery several months earlier and was taking Tramadol for pain, but it did not always help her knee pain. Her September 2025 MAR showed Tramadol was administered 14 times, with pain ratings ranging from 5 to 9. During wound care, she stated Tramadol was not helping her bilateral knee pain and asked that her doctor be notified about something stronger. The RN/wound care nurse contacted the doctor's nurse and was told the physician was out of town until the following week and would see the resident during rounds. The physician later ordered Lortab 7.5-325 mg every 12 hours as needed for pain, which was 6 days after the resident complained that Tramadol had not relieved her pain.
Delayed Response to Call Light Assistance Requests
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies to care for resident needs by not responding to call light assistance requests in a timely manner for Resident #41. Resident #41 was admitted with diagnoses including cerebral infarction, unspecified; weakness; other reduced mobility; and need for assistance with personal care. The resident's Quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and the active September 2025 plan of care directed staff to provide incontinence care as needed. During the survey, Resident #41 stated that staff did not come to the room in a timely manner when assistance was requested and reported that the bed was wet with urine and needed to be changed. The surveyor observed the resident press the call button and tell the nursing station that the bed was wet and needed to be changed. Later observation and interview showed that no staff member had come to the room to assist with incontinence care and linen change. The ADON confirmed that a staff member should have gone to the room to assist, and the Administrator was notified that staff did not respond to the call light in a timely manner. In resident council, complaints were also raised by two residents about excessive wait times for call light response, and other attendees agreed with those complaints.
Infection Prevention Program Not Maintained
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. For Resident #7, whose diagnoses included chronic respiratory failure, chronic systolic congestive heart failure, paroxysmal atrial fibrillation, cerebral infarction, type 2 diabetes mellitus with diabetic polyneuropathy, repeated falls, schizoaffective disorder, and major depressive disorder, the annual MDS showed a BIMS score of 10, indicating moderate cognitive impairment for daily decision making. The resident had an order dated 05/22/2024 to change oxygen tubing/humidifier bottle and clean the filter weekly on Thursday night shift, but on 09/23/2025 at 2:30 p.m. the oxygen concentrator was observed with no filter in place on either side, and the LPN charge nurse confirmed the filters were not present. The facility also failed to use disinfectant solution per the manufacturer's instructions in the shower room used by 40 of 52 residents. A CNA reported that shower stalls were cleaned between residents and that she immediately rinsed the area after applying the disinfectant, while the housekeeping supervisor stated the shower area was cleaned at the end of every day and said the solution required a 5 to 10 minute wait time before rinsing. The LPN charge nurse, who was also the infection preventionist, reported she was unaware whether the cleaning solution required a wait time before rinsing. Review of the manufacturer's documentation and the product label showed the solution required a 10 minute sit time, and the LPN charge nurse confirmed the facility failed to use the disinfectant per the manufacturer's instructions.
Unsafe Smoker Care Plan Not Followed
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident identified as an unsafe smoker. The resident had diagnoses including chronic obstructive pulmonary disease, other specified peripheral vascular diseases, acquired absence of the left leg below knee, history of falling, and dysphagia. The Quarterly MDS assessment documented a BIMS score of 9, indicating moderate cognitive impairment for daily decision making, and noted impairment to the upper and lower extremities bilaterally with range of motion. The active electronic plan of care as of 09/23/2025 identified a potential for injury related to smoking and classified the resident as an unsafe smoker. The smoking plan specified that the resident required a smoking apron, and the Quarterly Safe Smoking Assessment last reviewed 07/15/2025 also included use of a smoking apron. During a smoking observation in the designated smoking area, the resident was seen holding a lit cigarette in the right hand with no smoking apron in place. A CNA stated the resident did not require a smoking apron, while the ADON later observed the resident smoking without one and then reviewed the smoking list and confirmed that the resident did require a smoking apron.
Failure to Post Recent State Inspection Results
Penalty
Summary
The facility failed to ensure that the most recent state inspection results were available for resident review. During an observation on September 9, 2024, it was noted that while the results of the last annual survey from October 4, 2023, were posted by the front entrance, the results from the last complaint survey dated July 8, 2024, were not displayed. An interview with the administrator on September 10, 2024, confirmed that the most recent inspection results from July 8, 2024, were not posted for residents to review.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, as evidenced by observations of unclean conditions in multiple resident rooms and bathrooms. Specifically, the air conditioner vents in the rooms of residents #7, #22, and #55 were found to contain dirt, grime, and a black substance. Additionally, a washcloth and a paper towel were found lodged in the vents of residents #7 and #22, respectively. Resident #55's bathroom door frame also had a black substance on it. These observations were confirmed by the facility's administrator. Further deficiencies were noted in the room and bathroom of resident #46, where feces were observed on the toilet seat and brown splatter stains on the walls. The air conditioning unit in this room was surrounded by black mold and dirt. Additionally, the laundry room was found to have black mold on the wall behind the washing machine, and cleaning supplies were improperly stored directly on the floor. These conditions were also confirmed by the facility's administrator during an interview.
Failure to Cover Urinary Catheter Bag
Penalty
Summary
The facility failed to implement the care plan for a resident with a suprapubic urinary catheter, as evidenced by the resident's catheter bag not being covered with a privacy bag when outside of his room. The resident, who was admitted with multiple diagnoses including hemiplegia, epilepsy, and cognitive communication deficit, was observed on two separate occasions propelling himself in his wheelchair with the catheter bag exposed. The facility's policy requires catheter drainage bags to be covered at all times when the resident is out of their room. The resident, who had a Brief Interview of Mental Status score indicating no cognitive impairment, was seen on two occasions with his catheter bag hanging exposed under his wheelchair. The Director of Nursing confirmed that the resident's catheter bag should have been covered with a privacy bag while he was in his wheelchair outside of his room. This oversight indicates a failure to adhere to the facility's policy regarding catheter bag coverage, leading to the deficiency noted in the report.
Failure to Provide Proper Mobility Support
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. Resident #53, who has severe cognitive impairment and requires assistance with all Activities of Daily Living, was observed on two separate occasions sitting in a high back wheelchair with both feet dangling and not touching the floor. This improper positioning was confirmed by the Director of Nursing during an interview, indicating a deficiency in providing adequate care to maintain or improve the resident's range of motion and mobility.
Failure to Provide Colostomy Care as Per Care Plan
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident who required such services, as evidenced by the lack of availability of colostomy bags in accordance with the resident's care plan. The resident, who was admitted with multiple diagnoses including hemiplegia, epilepsy, and a colostomy, was observed using a makeshift colostomy bag made from a gallon-sized plastic storage bag secured with tape. This was due to the facility not having the correct size colostomy bags available for over a week, despite the care plan requiring a new colostomy bag to be applied daily. The resident, who had a BIMS score indicating no cognitive impairment, reported that the facility had been using the same bag for over a week, prompting him to create his own solution. The Director of Nursing confirmed the unavailability of new colostomy bags for the past week, highlighting a failure to adhere to the resident's comprehensive person-centered care plan. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails and did not review the risks and benefits of bed rails with the residents or their representatives, nor did they obtain informed consent prior to installation. This deficiency was identified for two residents who were reviewed for accident hazards. Resident #7, who had severe cognitive impairment and multiple medical conditions, had an assist bar installed on the left side of the bed without documented evidence of an assessment for entrapment risk or informed consent. Observations confirmed the presence of the assist bar, and the Director of Nursing acknowledged the lack of assessment and consent. Similarly, Resident #44, who also had severe cognitive impairment and required extensive assistance with activities of daily living, had two assist bars installed for bed mobility. There was no documented evidence of an assessment for entrapment risk or informed consent for this resident either. Observations confirmed the presence of the assist bars, and the Director of Nursing confirmed the absence of necessary assessments and consent. These actions and inactions led to the deficiency noted in the report.
Insufficient Weekend Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff with the appropriate competencies and skill sets to provide necessary nursing and related services. This deficiency was particularly evident during weekends from April 1, 2024, through June 30, 2024. The Payroll-Based Journal (PB&J) Staffing Data Report indicated extremely low weekend staffing levels for the third quarter of 2024. Interviews with the Business Office Manager confirmed the low staffing levels during this period. Specific dates in April, May, and June 2024 were identified where the staffing was insufficient, failing to meet the required staffing hours as per the facility's records and timesheets.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post nurse staffing information daily in a prominent location accessible to residents and visitors. On September 9, 2024, at 8:00 a.m., a surveyor observed that the daily staffing information was not visible in the facility. Later, at 11:00 a.m., the Director of Nursing (DON) disclosed that the staffing data was kept in a binder behind the nurses' station, which was not accessible to residents or visitors. An observation at 11:05 a.m. confirmed that the staffing data was indeed located in a black binder behind the nurses' station. On September 16, 2024, the DON acknowledged that the staffing data should have been posted in a visible area for residents and visitors.
Pharmacist Fails to Identify Medication Administration Irregularity
Penalty
Summary
The pharmacist failed to identify and report irregularities in the administration of Midodrine Hydrochloride for a resident with multiple diagnoses, including chronic kidney disease and orthostatic hypotension. The resident's medication was administered outside the prescribed parameters, which specified that the medication should not be given if the systolic blood pressure was above 120. Despite this, the medication was administered multiple times in August and September when the resident's systolic blood pressure exceeded the specified limit. The Consultant Pharmacist conducted a Medication Regimen Review for the resident in early September but did not document any issues regarding the inappropriate administration of Midodrine in August. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the pharmacy consultant did not identify the irregularity in the medication administration for the resident.
Unnecessary Drug Administration Due to Non-Adherence to Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. A review of the records for a resident with chronic kidney disease, orthostatic hypotension, fibromyalgia, type 2 diabetes mellitus, chronic atrial fibrillation, and hypertension revealed that Midodrine Hydrochloride was administered outside of the prescribed parameters. The medication was ordered to be given three times a day for orthostatic hypotension, with instructions to hold the dose if the systolic blood pressure was above 120. However, the August and September Medication Administration Records showed that Midodrine was administered multiple times despite the resident's systolic blood pressure being above 120, which was against the prescribed parameters. An interview with the Director of Nursing confirmed that the medication was administered on the specified dates in August and September, even though it should not have been given due to the blood pressure readings being outside the set parameters.
Improper Thawing of Meat Using Hot Water
Penalty
Summary
The facility failed to adhere to professional standards for food preparation by using hot water to thaw frozen meat. During an observation in the kitchen, it was noted that a dietary staff member was thawing frozen sausage in a sink with hot running water. Upon interview, the dietary staff member confirmed the use of hot water for thawing the sausage. Further interview with the facility administrator confirmed that the staff should not have used hot water for thawing meat. According to the United States Department of Agriculture (USDA) Safe Defrosting Methods, there are three safe ways to thaw food: in the refrigerator, in cold water, and in the microwave. The USDA guidelines explicitly state that perishable foods should never be thawed on the counter or in hot water.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). The incident occurred when the CNA, identified as S4CNA, physically abused a resident by bending the resident's finger and foot back and slapping the resident in the chest. This incident was witnessed by another CNA, S5CNA, and a Licensed Practical Nurse (LPN), S6LPN, who entered the room during the altercation. Despite witnessing the abuse, the staff did not immediately report the incident to the facility's administration, allowing the abusive CNA to continue working for several days following the incident. The resident involved in the incident had a history of chronic obstructive pulmonary disease, type 2 diabetes, heart failure, schizoaffective disorder, major depressive disorder, mood disorder, and cerebrovascular disease. The resident was known to be resistant to daily care, and the care plan included instructions to leave and approach the resident later if they became combative. On the day of the incident, the resident became upset during care, leading to the altercation with S4CNA. The facility's policy required immediate reporting and suspension of any staff involved in abuse allegations. However, this policy was not followed, as the CNA continued to work shifts after the incident. The facility also failed to initiate a quality assurance or performance improvement process to monitor for ongoing abuse and did not interview other residents to ensure no further abuse occurred. This oversight had the potential to affect all residents in the facility.
Failure to Report Resident Abuse and Implement Policies
Penalty
Summary
The facility failed to ensure that staff reported the physical abuse of a resident to administration immediately and did not implement policies and procedures for reporting a reasonable suspicion of a crime within 24 hours to law enforcement. The incident involved a resident with multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes, heart failure, schizoaffective disorder, and moderate cognitive impairment. The resident was physically abused by a CNA, witnessed by another CNA and an LPN, but the abuse was not reported to the administration or law enforcement in a timely manner. On the day of the incident, the resident became combative during care, leading to an altercation with the CNA, who physically abused the resident by bending his finger, slapping him, and bending his toes. Despite witnessing the abuse, the other CNA and LPN did not report the incident immediately to the administration. The abuse was only reported three days later, and the CNA involved continued to work additional shifts before being terminated. The facility's policy required immediate reporting of abuse to a supervisor and the suspension of the accused employee. However, the staff involved did not follow these procedures, and the administration was not informed until several days later. Additionally, the facility did not notify law enforcement within the required 24-hour period after becoming aware of the abuse, further compounding the deficiency.
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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 Wisner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary Anna Nursing Home | 0.8 mi | ★★★★★ | 8 | 2 |
| Plantation Manor Nursing And Rehab Center, Llc | 13.4 mi | ★★★★★ | 0 | 0 |
| Legacy Nursing And Rehabilitation Of Winnsboro | 14.1 mi | ★★★★★ | 0 | 0 |
| Camelot Leisure Living | 24.5 mi | ★★★★★ | 11 | 0 |
| Haven Nursing Center | 26.6 mi | ★★★★★ | 0 | 0 |
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