The Oaks
The Oaks in MONROE, LA — inspection on February 24, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the record revealed Resident #1 expired at the hospital on [DATE].
Further review of the record revealed no documented evidence of quarterly care plan meetings for Resident #1An interview on [DATE] at 11:15 a.m. with S4SSD confirmed she was hired in [DATE] and was responsible for scheduling care plan meetings quarterly for Resident #1 but had not scheduled any care plan meetings.An interview on [DATE] at 12:00 p.m. with S2DON confirmed the facility failed to conduct care plan meetings for Resident #1.Resident #2Review of Resident #2's record revealed an admission date of [DATE] with diagnoses including conversion disorder with seizures or convulsions, unspecified dementia severe with other behaviors disturbance, benign prostatic hypertrophy with lower tract symptoms, vascular dementia severe with agitation, primary syphilis of other sites, hypertension, malignant neoplasm of prostate, other acute kidney failure, other specified depressive episodes, repeated falls, other specified mental disorders due to known physiological condition.
Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. An interview on [DATE] at 11:15 a.m. with S4SSD confirmed she was hired in [DATE] and was responsible for scheduling care plan meetings quarterly for Resident #2 but had not scheduled any care plan meetings. S4SSD revealed the last care plan meeting for Resident #2 was on [DATE].An interview on [DATE] at 12:00 p.m. with S2DON confirmed the facility failed to conduct care plan meetings for Resident #2.
Resident #3Review of Resident #3's record revealed an admission date of [DATE] with diagnoses including Bell's Palsy, chronic pain syndrome, paroxysmal atrial fibrillation, gastro-esophageal reflux disease without esophagitis, chronic diastolic (congestive) heart failure, major depressive disorder, trigeminal neuralgia generalized anxiety disorder, metabolic encephalopathy, and Parkinson's disease.
Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. An interview on [DATE] at 11:15 a.m. with S4SSD confirmed she was hired in [DATE] and was responsible for scheduling care plan meetings quarterly for Resident #3 but had not scheduled any care plan meetings.An interview on [DATE] at 12:00 p.m. with S2DON confirmed the facility failed to conduct care plan meetings for Resident #3.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
195542 02/24/2026
The Oaks 1000 McKeen Place Monroe, LA 71201
authorities.
record review and interviews, the facility failed to ensure all allegations of injuries of unknown source
Administrator for 1 (#1) of 4 sampled residents.Findings:
Review of the facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating Policy and Procedure, revision date [DATE], revealed the following, in part:Policy StatementAll reports of resident abuse (including injuries of unknown origin), neglect/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management.
Findings of all investigations are documented and reported.Policy Interpretation and ImplementationReporting Allegations to the Administrator and Authorities1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2.
The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a.
The state licensing/certification agency responsible for surveying/licensing the facility.3.
Immediately is defined as:a.
Within two hours of the allegation involving abuse or result in serious bodily injury.Review of Resident #1's record revealed an admission date of [DATE] with diagnoses including unspecified atrial fibrillation, unspecified fractures of ribs right side, type 2 diabetes mellitus without complications, stroke, hypertension, and age related osteoporosis without current pathological fracture.
Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating no cognitive impairment.
Further review of MDS revealed resident required supervision or touching assistance with bed mobility, transfers, and toileting, and partial/moderate assistance with bathing.
Resident had no functional limitations in ROM to upper and lower extremities and no falls since her last MDS assessment.Review of the facility reported incident dated [DATE] for Resident #1 revealed the resident was found lying on her stomach in her room by S3LPN on [DATE] around 6:30 a.m.
Further review revealed Resident #1 was unresponsive and had a hematoma to the right side of her head and a laceration to the back of her head on the right side, and blood was noted on the floor. S3LPN sent Resident #1 to the local emergency room by the ambulance service, and the resident expired at the hospital on [DATE].An interview on [DATE] at 4:40 p.m. with S2DON revealed she was notified on [DATE] around 7:00 a.m. by S3LPN that Resident #1 was found on the floor unresponsive with a hematoma to the right side of her head and a laceration to back of right side of her head. S2DON confirmed she notified S1Corporate Administrator about this fall on [DATE] at 9:15 a.m., but failed to notify him the fall was unwitnessed with serious bodily injury which included unresponsiveness with a hematoma to the right side of her head and a laceration to the back of her head. An interview on [DATE] at 11:40 a.m. with S3LPN revealed she was working the night shift on [DATE] with Resident #1. S3LPN reported when she went into resident's room to administer her morning medications around 6:30 a.m. she found Resident #1 lying face down on the floor in her room and she was unresponsive, she assessed resident for injuries and found a bruise to the side of the resident's head and a laceration to the back of the resident's head. S3LPN reported she notified S2DON of this incident on [DATE] around 7:00 a.m.An interview on [DATE] at 10:30 a.m. with S1Corporate Administrator confirmed he was notified of Resident #1 having a fall on [DATE] at 9:15 a.m. by S2DON with no additional details. S1Corporate Administrator confirmed S2DON should have notified him immediately of Resident #1's unwitnessed fall which resulted in serious bodily injury including unresponsiveness with a hematoma and laceration to her head.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.