SHREVEPORT, LA - Federal inspectors issued an immediate jeopardy citation to Southern Oaks Nursing & Rehabilitation Center after a certified nursing assistant was witnessed engaging in sexual intercourse with a resident and the facility failed to report the incident as abuse, according to a complaint survey completed on March 17, 2025.
CNA Witnessed Having Sex With Resident
According to the federal inspection report, on March 1, 2025, at approximately 5:50 a.m., a CNA (identified as S4 in the report) entered a resident's room and observed a fellow CNA (identified as S3) having sexual intercourse with Resident #1.
The witnessing CNA immediately left the room and reported what she observed to the on-duty nurse. However, the sexual act between S3 and Resident #1 was still in progress when S4 departed the room, meaning the resident was left without any immediate intervention or protection during the incident.
This detail became a central finding of the federal investigation: not only had a staff member engaged in a sexual act with a resident, but the facility's own training and policies had instructed staff to leave the scene of an abuse incident rather than stay to protect the victim.
Facility Did Not Report Incident as Abuse
Perhaps equally alarming was the facility's response — or lack thereof — in the days following the incident. During an interview with inspectors on March 13, 2025, the facility's administrator (identified as S1) stated that Southern Oaks did not report the incident because he "did not recognize it was abuse because it was consensual."
This characterization directly contradicts federal nursing home regulations. Under federal law, any sexual contact between a staff member and a nursing home resident constitutes abuse, regardless of whether the resident appears to consent. The power imbalance inherent in the caregiver-resident relationship makes meaningful consent impossible in such situations. Staff members hold authority over residents' daily care, medications, meals, and basic needs — creating a dynamic where a resident cannot freely refuse or consent to sexual contact.
Federal regulations under 42 CFR §483.12 are explicit: nursing facilities must prohibit and prevent abuse of residents, and sexual abuse by staff is always classified as abuse. Facilities are required to report all allegations of abuse to the state survey agency and to law enforcement within specified timeframes.
By failing to report the incident, Southern Oaks potentially delayed any criminal investigation, denied the resident access to victim advocacy services, and left other residents at continued risk.
Flawed Training Left Residents Unprotected
The investigation revealed a systemic failure in how Southern Oaks trained its staff to respond to witnessed abuse. During interviews conducted on March 13 and March 17, 2025, both the facility's Director of Nursing (S2) and Corporate Nurse (S5) confirmed that CNAs had been trained according to facility policy to immediately leave the room and find a nurse when they witnessed abuse — rather than staying with the victim and attempting to intervene.
The Corporate Nurse told inspectors that "S4 CNA had done the appropriate thing in immediately notifying a nurse after witnessing the 03/01/2025 incident." The DON similarly confirmed that CNAs had been instructed to "immediately get a nurse when an abuse incident was observed and the nurse would then intervene."
However, this training was fundamentally inadequate. The correct protocol, according to federal standards, requires any staff member who witnesses abuse to immediately intervene to protect the resident while simultaneously calling for help. Leaving a resident alone with an abuser — even briefly — places that resident at continued risk of harm.
During a later interview on March 17, the administrator and Corporate Nurse acknowledged the failure after reviewing the applicable regulations. They confirmed that S4 "should have stayed with Resident #1 and attempted to intervene while calling for help." They further admitted that "an administrative breakdown had occurred" when staff had not been trained to call for help immediately and to stay with residents in an abuse situation.
The Responsibility Chain
Inspectors traced the failure up the chain of command. The administrator was identified as the designated oversight person responsible for ensuring deficient practices did not occur and that staff received proper training on correct policies and procedures. The Corporate Nurse reported that training oversight for the administrator and administrative staff fell to the Nursing Home Administrator Supervisor and the Chief Operating Officer.
A review of the facility's Abuse/Neglect Prevention Program, which had been revised in September 2021, confirmed it failed to include provisions for immediate staff response to protect alleged victims of physical and psychosocial harm during and after an investigation.
Why Staff-on-Resident Sexual Abuse Is Particularly Harmful
Sexual abuse of nursing home residents by staff members represents one of the most serious violations a facility can receive. Residents in long-term care settings are often physically frail, cognitively impaired, or dependent on staff for their most basic needs. This dependency creates a profound vulnerability.
The psychological impact on victims of staff-on-resident sexual abuse can be severe and long-lasting. Residents may experience anxiety, depression, post-traumatic stress, sleep disturbances, and a deep erosion of trust in the people responsible for their care. For residents with cognitive impairments, the trauma may manifest as behavioral changes, agitation, withdrawal, or refusal of care — symptoms that can be misattributed to their underlying condition rather than recognized as responses to abuse.
The physical consequences can also be significant. Elderly residents are at elevated risk for injury during sexual contact due to age-related tissue fragility, and the risk of sexually transmitted infections is a medical concern that requires evaluation and potential treatment.
Federal regulators classify staff sexual contact with residents as abuse precisely because the caregiver-resident relationship precludes genuine consent. This standard exists regardless of a resident's cognitive status or apparent willingness, because the power dynamic inherent in institutional care fundamentally compromises any resident's ability to freely consent.
Immediate Jeopardy and Corrective Actions
Inspectors designated the deficiency at the immediate jeopardy level — the most serious classification in the federal survey system. An immediate jeopardy citation indicates that the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.
The citation was issued under F-Tag 0835, which addresses the facility's administration and its responsibility to ensure compliance with federal requirements and to maintain quality oversight systems.
As part of its Plan of Removal, Southern Oaks implemented several corrective actions:
- On March 14, 2025, the Nursing Home Administrator Supervisor conducted an in-service training session for the administrator covering the prohibition on sexual relationships between staff and residents — even those characterized as consensual — and the requirement for immediate intervention to protect victims.
- On March 15, 2025, a baseline competency interview was administered to the administrator by the DON to verify that the training content had been learned and retained. The competency assessment included questions about the prohibition on staff-resident sexual activity, the definition of sexual abuse, and the proper immediate response to protect residents.
- The facility implemented a QAPI (Quality Assurance and Performance Improvement) monitoring plan requiring random staff interviews three times per week for six weeks, then monthly thereafter. The interviews are designed to verify that staff understand what constitutes sexual abuse, how to provide immediate protection to residents, and how to respond appropriately when abuse is witnessed.
- Effectiveness of the corrective actions was to be reviewed weekly for six weeks at QAPI meetings, with additional training or corrective measures implemented as needed.
The facility asserted compliance as of March 17, 2025, and stated that the likelihood for serious harm to any resident no longer existed as of that date.
A Pattern of Regulatory Concern
The incident at Southern Oaks highlights a recurring problem identified by federal regulators across the long-term care industry: facilities that fail to recognize staff-on-resident sexual contact as abuse, and training programs that inadequately prepare frontline workers to respond to abuse in progress.
The fact that Southern Oaks' abuse prevention program had not been updated since 2021 — and that it lacked basic provisions for immediate victim protection — raises questions about the adequacy of the facility's overall compliance infrastructure. The administrator's statement that he did not recognize the incident as abuse because it was "consensual" suggests a fundamental misunderstanding of federal regulations at the highest level of facility leadership.
Families of residents at Southern Oaks or any nursing facility who have concerns about potential abuse should contact the Louisiana Long-Term Care Ombudsman Program or file a complaint with the Louisiana Department of Health. Federal law protects residents' right to be free from abuse, and facilities are required to investigate all allegations and report findings to the appropriate authorities.
The full inspection report for Southern Oaks Nursing & Rehabilitation Center is available through the Centers for Medicare & Medicaid Services and contains additional details about the findings and corrective actions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southern Oaks Nursing & Rehabilitation Center from 2025-03-17 including all violations, facility responses, and corrective action plans.
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