Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Southern Oaks Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A CNA engaged in sexual intercourse with a resident who had cognitive and physical impairments. The incident was witnessed by another CNA and confirmed by the resident, who reported the act as consensual. Facility leadership failed to recognize and report the event as sexual abuse, despite policies prohibiting such conduct and defining it as an abuse of power.
A facility failed to implement policies requiring staff to provide immediate protection to a resident during an alleged sexual abuse incident. A CNA witnessed another CNA engaging in sexual activity with a resident and, following policy, left the scene to report to a nurse, leaving the resident unprotected. Leadership confirmed staff were trained only to report incidents, not to intervene directly.
A CNA was witnessed engaging in sexual intercourse with a resident who had aphasia but intact cognition. The witnessing CNA left the room to report the incident to a nurse, following facility policy, but did not intervene or provide immediate protection. The facility's abuse prevention program lacked guidance for immediate response, and staff were not trained to intervene directly, resulting in Immediate Jeopardy.
A resident with expressive aphasia was repeatedly assessed as severely cognitively impaired using the Staff Assessment for Mental Status, despite being cognitively intact and able to communicate needs through limited speech and gestures. Staff interviews and a recent BIMS assessment confirmed the resident's cognitive intactness, revealing that prior assessments did not accurately reflect the resident's true status.
A facility failed to notify law enforcement after a CNA was observed engaging in sexual intercourse with a resident who had significant neurological and psychiatric diagnoses. Although the incident was reported internally, the Administrator did not contact police, contrary to facility policy and federal requirements. Staff later acknowledged the event was sexual abuse and should have been reported.
The facility failed to follow care plans for two residents, resulting in missed medication doses and monitoring tasks. One resident did not receive prescribed doses of Humulin R, Lantus, and Gabapentin, while another missed doses of Insulin Aspart, Levothyroxine, Protonix, and Hydralazine, along with necessary monitoring. The DON confirmed the lack of documentation, indicating non-compliance with physician orders.
A cognitively impaired resident with communication deficits was verbally abused by a CNA during a whirlpool bath, where the CNA threatened the resident with physical harm. The incident was witnessed by an LPN who did not report it immediately. The resident later attempted to communicate the incident to the DON, and the situation was eventually reported by another CNA. The facility's investigation confirmed the abuse, leading to the termination of the CNA and the LPN.
A resident with cognitive deficits and multiple medical conditions was verbally threatened by a CNA during a whirlpool bath. An LPN intervened but did not report the incident immediately to the DON or administrator. The administrator was informed the next day but failed to report the incident to the State Survey Agency within the required two-hour window, resulting in a delay of two days before the report was made.
The facility failed to provide hand rolls for a resident with bilateral hand contractures, despite physician orders and a care plan requiring their use. Observations and interviews confirmed the absence of hand rolls over several days, leading to a deficiency in care.
Failure to Protect Resident from Sexual Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse and psychosocial harm by a staff member. A Certified Nursing Assistant (CNA), who was the primary caregiver for a resident with diagnoses including hemiplegia, hemiparesis, bipolar disorder, depression, and aphasia, engaged in sexual intercourse with the resident in his bed. The incident was directly observed by another CNA, who entered the room and witnessed the act taking place. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, confirmed during an interview that the sexual activity occurred and stated it was consensual. Despite the resident's cognitive status and his report of consent, the facility's staff failed to recognize that any sexual relationship between a staff member and a resident constitutes an abuse of power and is considered sexual abuse, regardless of apparent consent. The Administrator did not initially report the incident, stating he did not recognize it as abuse because it was consensual. The facility's abuse and neglect policy, which prohibits all forms of abuse including sexual abuse by staff, was not followed in this case. Interviews with staff confirmed that the CNA involved was immediately told to leave the facility after the incident was reported to nursing staff. The Director of Nursing and other administrative staff later acknowledged that the incident was sexual abuse and an abuse of power. The failure to recognize and report the incident as abuse, as well as the occurrence of the sexual act itself, constituted a deficiency in protecting residents from all forms of abuse as required by facility policy and federal regulations.
Removal Plan
- Review and update the facility's abuse and neglect policy to include statements clarifying that any sexual relationship between staff and residents is considered an abuse of power.
- Inservice the nursing facility staff on changes to the abuse and neglect policy and conduct baseline competency interviews.
- Remove the accused employee from the facility pending investigation.
- Examine the resident for injury and interview the resident.
- Interview the witness to the event.
- Interview the accused.
- Inservice all staff regarding abuse and neglect, including sexual abuse.
- Interview all interviewable residents to determine if they had witnessed or had a sexual encounter with a staff member.
- Physically examine all non-interviewable residents for any evidence of a sexual encounter.
- Conduct staff interviews to determine if they had witnessed or had knowledge of any staff sexual encounters.
- Assign two employees to care for the resident.
- Notify the resident's responsible party and nurse practitioner of the situation.
- Meet with the resident council to discuss concerns regarding the incident and encourage residents to report any issues.
- Make medication changes for the resident as indicated by the nurse practitioner.
- Terminate the accused from the facility.
- Have the facility psych nurse practitioner visit the resident and have the social services director reach out to in-house counseling services to determine eligibility for counseling related to the event.
- Implement monitoring of residents and staff using a post-event monitor and ask questions to determine if any inappropriate staff sexual behavior had been witnessed or suspected; continue monitoring until compliance is assured.
- Discuss the event and corrective actions at the QAPI meeting, and implement any corrective actions based on the interviews.
Failure to Provide Immediate Protection During Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to develop and implement written policies and procedures that ensured immediate protection of an alleged victim from physical and psychosocial harm during and after an investigation of abuse. The existing abuse/neglect prevention program required staff to report incidents to a supervisor or nurse but did not specify actions to provide immediate protection to the resident during an incident. This omission was evident when a CNA witnessed another CNA engaging in sexual intercourse with a resident and, following facility policy, left the room to report the incident to a nurse, leaving the resident and the alleged perpetrator alone. The incident involved a resident with aphasia, limited speech, but intact cognition, who was able to make his needs known. The resident later reported that the sexual activity was consensual. However, the report determined that a reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, given the expectation of safety in a healthcare facility. The CNA who witnessed the event did not intervene or provide immediate protection, as she was trained to report to the nurse and not to take direct action to protect the resident. Interviews with facility leadership confirmed that staff were trained according to the policy, which only required immediate reporting to a nurse, not direct intervention. The Director of Nursing and Corporate Nurse both stated that CNAs were taught to notify the nurse, who would then intervene. Upon review of regulations, facility leadership acknowledged that the policy lacked guidance on immediate protection for residents during incidents of alleged abuse.
Removal Plan
- Review and update the facility's abuse and neglect policy to include immediate physical and psychological protection of the alleged victim during and after the investigation, and to protect the integrity of the investigation.
- Implement procedures for the victim of abuse to be examined for physical and psychological injuries and medically treated as indicated.
- Establish increased supervision of the alleged victim and residents as necessary, depending on circumstances.
- Implement room and/or staffing changes as necessary to protect the resident from the alleged perpetrator.
- Require staff to protect the victim from retaliation and provide emotional support and counseling during and after the investigation, as needed.
- Initiate inservice training for all facility staff on the updated abuse and neglect policy, including immediate protection measures and intervention steps.
- Ensure all staff receive inservice training prior to starting their shift if not already trained, using a personnel roster to track completion.
- Conduct baseline competency interviews with each staff member following inservice to ensure understanding and retention of the new procedures.
- Require immediate reinservice for any staff member who answers competency interview questions incorrectly.
- Implement a QAPI monitor to assure sustained compliance by interviewing random staff members about sexual abuse definitions and immediate protection procedures.
- Discuss effectiveness of corrective actions at QAPI meetings, with findings added to QAPI minutes and additional inservices or corrective actions implemented as needed.
Failure to Protect Resident from Staff Sexual Abuse and Provide Immediate Protection
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to protect a resident from abuse and to ensure immediate protection following an incident involving a staff member. A certified nursing assistant (CNA) was witnessed by another CNA engaging in sexual intercourse with a resident who had aphasia but intact cognition. The witnessing CNA left the room to report the incident to a nurse, as per facility policy, but did not intervene or provide immediate protection to the resident while the act was ongoing. The facility's abuse prevention program did not include guidance for staff on immediate response to protect an alleged victim during and after an incident. Interviews with the administrator, DON, and corporate nurse revealed that staff had only been trained to report abuse to a nurse, not to intervene directly or remain with the resident to ensure their safety. The administrator did not initially recognize the incident as abuse due to the resident's apparent consent, and the facility did not report the incident as required. Further interviews confirmed that the CNA who witnessed the abuse followed existing policy, which was inadequate for immediate resident protection. The administrator and corporate nurse later acknowledged that staff should have been trained to intervene and stay with the resident in such situations. The lack of effective policies, staff training, and immediate protective actions led to the finding of Immediate Jeopardy.
Removal Plan
- Inservice training provided to the Administrator by the NHA Supervisor on the responsibilities of nursing facility staff to protect residents and recognize that any sexual relationship between staff and residents is considered abuse of power.
- All staff instructed to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation.
- Victims of abuse to be examined for physical and psychological injuries and medically treated as indicated.
- Increased supervision of the alleged victim and residents as necessary, depending on the circumstances.
- Room and/or staffing changes to be made as necessary to protect the resident from the alleged perpetrator.
- Staff instructed to protect the victim from retaliation and provide emotional support and counseling during and after the investigation, as needed.
- Baseline competency interview completed with the Administrator to ensure understanding and retention of the inservice content, with immediate reinservice if any questions are answered incorrectly.
- QAPI monitoring implemented by interviewing random staff members to ensure staff awareness of immediate protection procedures during and after an abuse investigation.
- Effectiveness of corrective actions to be discussed at the QAPI Meeting, with findings added to the QAPI minutes and additional inservices or corrective actions implemented as needed.
Inaccurate Cognitive Assessment Due to Misuse of Staff Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected the resident's cognitive status during the observation period. Record review showed that the resident, who had a history of cerebral infarction, aphasia, hemiplegia, hypertension, diabetes, and mood disorders, was consistently assessed using the Staff Assessment for Mental Status on multiple MDS (Minimum Data Set) assessments over the past year. These assessments indicated severe cognitive impairment, despite the resident's care plan and staff interviews confirming that the resident was cognitively intact but had expressive aphasia, limiting verbal communication to a few words, gestures, and head movements. Interviews with the ADON, Administrator, Corporate Nurse, NP, Social Services, and MDS Nurse all confirmed that the resident was able to communicate needs and was cognitively intact, despite expressive limitations. It was revealed that the BIMS (Brief Interview for Mental Status) was not conducted previously, as staff believed the resident was rarely or never understood. However, a recent BIMS assessment, using alternative communication methods such as words and pictures, resulted in a score indicating cognitive intactness. The use of the Staff Assessment for Mental Status instead of the BIMS led to inaccurate documentation of the resident's cognitive abilities.
Failure to Report Suspected Sexual Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically by not notifying local law enforcement of an alleged incident of sexual abuse involving a resident and a Certified Nursing Assistant (CNA). According to the facility's Abuse/Neglect Prevention Program, any evidence or suspicion of abuse, including sexual abuse, must be immediately reported to the Administrator and appropriate authorities, including law enforcement. However, after a CNA witnessed another CNA engaging in sexual intercourse with a resident, the incident was reported internally but not to the police, as the Administrator determined the act was consensual. The resident involved had a medical history including hemiplegia and hemiparesis following a cerebral infarction, bipolar disorder, recurrent depressive disorders, and aphasia. Interviews with facility staff confirmed that law enforcement was not notified of the incident, despite the facility's policy and later acknowledgment by the Administrator and a corporate nurse that the event constituted sexual abuse and should have been reported to the police.
Failure to Follow Care Plans for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that the care plans for two residents were followed, specifically regarding the administration of medications and monitoring as per physician orders. For Resident #2, the medical record indicated a failure to administer prescribed doses of Humulin R, Lantus, and Gabapentin on multiple occasions throughout July 2024. This resident had a medical history including rheumatoid arthritis, chronic venous insufficiency, long-term insulin use, and diabetes mellitus with hyperglycemia. The Medication Administration Record (MAR) lacked evidence of medication administration on specified dates, indicating non-compliance with the care plan. Similarly, for Resident #3, the facility did not adhere to physician orders for administering Insulin Aspart, Levothyroxine, Protonix, and Hydralazine, as well as performing necessary monitoring tasks such as changing nebulizer equipment, checking edema status, and documenting seizure activity. This resident's medical history included type 2 diabetes mellitus, acute and chronic respiratory failure, myocardial infarction, and other complex conditions. The Director of Nursing acknowledged the missing documentation in the MAR, confirming that the medications and monitoring tasks were not completed as required, which constitutes a deficiency in following the care plan.
Verbal Abuse Incident Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse and psychosocial harm by a staff member. The incident involved a cognitively impaired resident with communication deficits who was verbally abused by a certified nursing assistant (CNA) during a whirlpool bath. The resident, who had a history of cerebral vascular accident, aphasia, and other medical conditions, became agitated during the bath and did not want his hair washed. In response, the CNA threatened the resident with physical harm, using derogatory language. The incident was witnessed by a licensed practical nurse (LPN) who heard the commotion and intervened by instructing the CNA to step away from the resident. Despite witnessing the verbal abuse, the LPN did not immediately report the incident to a supervisor. The resident later attempted to communicate the incident to the Director of Nurses (DON) but was unable to do so effectively due to his communication deficits. The situation was eventually brought to the attention of the DON by another CNA who had overheard the incident. The facility's investigation confirmed the verbal abuse through statements from staff members who were present during the incident. The CNA involved was placed on administrative leave and subsequently terminated. The LPN who witnessed the abuse but failed to report it was also terminated. The facility's failure to protect the resident from verbal abuse and the delay in reporting the incident constituted a deficiency in the care provided to the resident.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse by a certified nursing assistant (CNA) towards a resident in a timely manner, as required by their Abuse/Neglect Prevention program. The incident involved a resident with significant cognitive deficits and multiple medical conditions, including cerebral vascular accident with right-sided hemiplegia, aphasia, apraxia, dysphasia, diabetes, bipolar disease, and hypertension. During a whirlpool bath, the resident became frustrated and allegedly attempted to get the CNA to leave him alone. In response, the CNA verbally threatened the resident. A licensed practical nurse (LPN) nearby heard the commotion and intervened, instructing the CNA to step away from the resident. However, the LPN did not report the incident to the director of nurses (DON) or the administrator immediately, as required by the facility's policy. The director of nurses was informed of the incident the following day, and the administrator was notified thereafter. Despite being aware of the incident, the administrator failed to report the allegation to the State Survey Agency within the mandated two-hour window. The incident was eventually reported to the State Survey Agency two days after it occurred, which was not in compliance with the facility's policy and state regulations. This delay in reporting represents a deficiency in the facility's adherence to abuse reporting protocols.
Failure to Provide Hand Rolls for Resident with Bilateral Hand Contractures
Penalty
Summary
The facility failed to provide services to prevent further contractures and potential decline in range of motion for a resident with bilateral hand contractures. Resident #22, who was cognitively intact and had a BIMS score of 15, had physician orders and a care plan that required the application of hand rolls to both hands every morning and their removal every afternoon. However, observations on multiple occasions revealed that the resident did not have hand rolls in place, and interviews confirmed that the hand rolls had been removed for cleaning and not returned for several days. The resident's medical record indicated diagnoses including quadriplegia and multiple contractures. Despite the care plan's specific instructions, the resident was observed without hand rolls on three separate days. Interviews with the resident and staff confirmed the absence of the hand rolls, with the CNA and LPN acknowledging that the hand rolls should have been in place. The failure to provide the necessary hand rolls as per the care plan and physician orders led to the deficiency noted in the report.
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What surveyors actually found near you
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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 Shreveport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Progressive Care Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Willis-knighton Extended Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Harmony House Nursing And Rehabilitation Center, I | 1.9 mi | ★★★★★ | 5 | 0 |
| Shreveport Manor Skilled Nursing & Rehabilitation | 2 mi | ★★★★★ | 8 | 0 |
| Roseview Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 12 | 1 |
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