F 0656 -Nutrition with interventions that included, in part, potential for altered nutrition and dehydration, resident often refuses renal diet, weight fluctuations over last year, receiving hemodialysis 3 times a week, resident is Level of Harm - Minimal harm or on a regular texture diet and Nepro supplement. potential for actual harm

During an interview on 05/21/2025 at 12:40 p.m. S1 DON (Director of Nursing) reviewed Resident #28's Residents Affected - Some medical record and confirmed monitoring for s/s of dialysis site infection and consumption of Nepro supplement should have been entered as per the physician order and was not.

During an interview on 05/21/2025 at 12:53 p.m. S3 LPN (Licensed Practical Nurse) reviewed Resident #28's MAR and confirmed 0 or 1 had not been entered to indicate whether Resident #28's dialysis access site had s/s of infection and confirmed no number was present to indicate how much Nepro supplement Resident #28 had consumed and there should have been per the physician order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 195558 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195558 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southern Oaks Nursing & Rehabilitation Center 1524 Glen Oaks Place Shreveport, LA 71103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During an interview on 05/21/2025 at 10:15 a.m., S1DON (Director of Nursing) acknowledged Resident #17 did not have a physician's order in place for oxygen therapy and should. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 195558 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195558 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southern Oaks Nursing & Rehabilitation Center 1524 Glen Oaks Place Shreveport, LA 71103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45317 potential for actual harm Based on record review and interviews, the facility failed to administer a medication as ordered for 1 (#25) of Residents Affected - Some 5 (#10, #22, #25, #27, #49) sampled residents reviewed for unnecessary medications.

Findings:

Review of Resident #25's medical record revealed in part an initial admitted [DATE REDACTED]. Further review of Resident #25's medical record revealed diagnoses including, but not limited to bipolar disorder and paranoid schizophrenia.

Review of Resident #25's physician orders revealed, in part, an order dated 05/02/2025 to increase Risperdal 1 milligram (mg) to twice a day (BID).

Review of Resident #25's May 2025 medication administration record (MAR) from 05/03/2025 to 05/20/2025 revealed in part, Resident #25 received Risperdal 1mg one tablet by mouth (po) at bedtime (HS).

During an interview on 05/21/2025 at 9:49 a.m., S3 Licensed Practical Nurse (LPN) reviewed Resident #25's May 2025 MAR and reported Resident #25 received Risperdal 1mg po at HS.

During an interview on 05/21/2025 at 11:27 a.m., S1 Director of Nursing (DON) confirmed Resident #25 had

an order dated 05/02/2025 to increase Risperdal 1mg po to BID. S1DON reviewed Resident #25's May 2025 MAR and confirmed Resident #25 had not received Risperdal 1mg 1 po BID as ordered on 05/02/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 195558 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195558 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southern Oaks Nursing & Rehabilitation Center 1524 Glen Oaks Place Shreveport, LA 71103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -S5 CNA degloved, put on hand sanitizer and new gloves, dipped a clean washcloth in water with soap, wrung it out, and was observed wiping up left groin area, across and under abdominal fold and down the Level of Harm - Minimal harm or right groin area and proceeded with the same washcloth and wiped between labia starting in the back and potential for actual harm wiped toward the front.

Residents Affected - Few During an interview on 05/21/2025 at 11:15 a.m. S1 DON (Director of Nursing) confirmed during peri-care female residents should be cleaned from front to back.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 195558