Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ascension Oaks Nursing & Rehab Center during CMS and state inspections, most recent first.
Staff failed to accurately document the administration or omission of multiple prescribed medications and supplements for two residents in the eMAR, resulting in missing records and signatures for several medications, as confirmed by the DON and facility policy.
The QAPI committee did not provide evidence of ongoing monitoring or evaluation to ensure corrective actions were implemented after identifying the need to monitor coffee temperatures. Despite in-service training and daily audits, coffee was served above the recommended temperature range, and no corrective action or review by the QAPI committee was documented.
A resident with an active diagnosis of bipolar disorder was not referred for a required PASARR Level II evaluation by the facility. Review of records and staff interview confirmed that the necessary referral to the state behavioral health office was not made since the resident's admission.
Surveyors observed that food was served to residents at temperatures below the expected standard, with several residents reporting their meals were cold or lukewarm. Staff left the tray cart door open during meal delivery, and food temperature checks confirmed items were not at the required serving temperature. The dietary manager acknowledged delays in meal service contributed to the issue.
Staff failed to properly seal and label opened frozen food items and did not follow required procedures for sanitizing dishware in the 3 compartment sink, including monitoring water temperatures and soak times as specified by manufacturer instructions.
A wound care nurse failed to perform hand hygiene between glove changes while providing wound care to a resident, despite facility policies requiring handwashing before and after resident contact and during dressing changes. This deficiency was confirmed by interviews with the nurse, the infection preventionist, and the DON.
A resident in a semi-private room was found to be without a required ceiling-suspended privacy curtain around their bed, despite sharing the room with a roommate. Staff and the administrator confirmed the absence of the curtain and acknowledged it should have been in place to ensure privacy.
A resident sustained a serious head injury after falling from a mechanical lift due to staff failing to inspect the sling and locking the lift's brakes during transfer, contrary to the manufacturer's guidelines. The facility also did not follow proper laundering procedures for the lift slings, potentially compromising their integrity.
A facility failed to ensure staff were trained and competent in using a mechanical lift, leading to a resident's fall and serious injury. The CNA did not inspect the lift sling properly and locked the brakes against the manufacturer's guidelines. The CNA Supervisor and other responsible staff were unaware of the correct procedures, and no documented competency evaluation was available.
A resident was injured due to improper use of a mechanical lift in a facility. Staff failed to inspect the lift sling for damage and did not unlock the lift's brakes during transfer, resulting in the resident falling and sustaining a serious injury. Additionally, the facility did not follow manufacturer's guidelines for laundering lift slings, and there was no evidence of staff competency evaluations for using the lift.
The facility's assessment was incomplete, missing critical components such as staff competencies, physical environment and equipment, and cultural factors. The Regional Director of Operations confirmed the oversight during an interview, acknowledging that Section 3, which should have covered these areas, was not completed.
The facility failed to provide required training on resident rights and facility responsibilities to several CNAs, including a supervisor. Personnel records for staff hired between 2014 and 2023 lacked documentation of this training. The administrator confirmed the absence of evidence for the required training.
Two cognitively intact residents were not invited to participate in their care plan meetings, as evidenced by the absence of scheduled times on the facility's list and confirmed by the residents themselves. The facility's social services staff acknowledged the lack of documented evidence of invitations, despite the interdisciplinary team meeting with residents individually before care plan meetings.
The facility did not conduct annual performance evaluations or provide training for several CNAs and their supervisor. Personnel records showed no evidence of evaluations for CNAs hired between 2016 and 2023. Interviews confirmed the absence of evaluations, with the CNA Supervisor and Administrator acknowledging the oversight.
A facility failed to maintain accurate blood glucose records for a resident. The resident had a physician's order for Novolog based on a sliding scale, but the eMAR showed discrepancies, including undocumented blood glucose levels and vague documentation. The Assistant DON acknowledged these inaccuracies and emphasized the need for precise documentation.
The facility failed to provide required QAPI training to several CNAs, including a supervisor, as evidenced by the absence of documentation in their personnel records. The administrator confirmed the lack of training records, highlighting a deficiency in staff training on the QAPI program.
The facility failed to provide documented infection control training for CNAs, including a supervisor, hired between 2014 and 2023. An interview with the administrator confirmed the absence of required training documentation, indicating a systemic issue in the facility's infection prevention and control program.
The facility failed to provide required compliance and ethics training to its CNA staff, including a CNA Supervisor, as evidenced by the absence of documentation in their personnel records. The administrator confirmed the lack of training records for staff hired between 2014 and 2023.
A facility failed to ensure a resident's call light button was within reach, as required by the care plan. The resident, who is bed-bound, had the call light button placed at the base of the bed or at their feet, making it unreachable. CNAs and the Assistant Director of Nursing confirmed that the call light should have been accessible.
A resident's code status was not updated in the EMR to reflect their advance directive, which indicated Do Not Resuscitate (DNR). Despite being notified of the change, the LPN Medicare Nurse Manager delayed updating the EMR, resulting in a discrepancy between the resident's wishes and their documented code status. The facility's administrator confirmed the oversight.
Two residents in an LTC facility received improper catheter care, leading to deficiencies. A resident's catheter bag was found on the floor, which is unsanitary. Another resident, with a history of UTIs, had their catheter area cleaned with contaminated water by a CNA, which was acknowledged as incorrect by the CNA and the Assistant DON.
The facility failed to properly contain soiled linen, as observed in a resident's room where linens were left on the floor, emitting a urine odor. The resident expressed dissatisfaction, and a CNA confirmed the linens should not have been on the floor. The administrator acknowledged the issue but did not elaborate further.
Failure to Accurately Document Medication Administration in eMAR
Penalty
Summary
The facility failed to maintain and accurately document the electronic Medication Administration Record (eMAR) for two residents, as required by professional standards and the facility's own policy. Review of the medical records policy indicated that staff are expected to record all care provided, including medication administration, and to document any adverse reactions or abnormalities. However, for two residents, there was no documented evidence in the eMAR that multiple prescribed medications and supplements were either administered or not administered on several specified dates and times. This included medications for insomnia, constipation, pain, mood disorders, anxiety, nutritional supplementation, and blood thinning. Interviews and record reviews confirmed that the required documentation was missing for these residents, and the Director of Nursing acknowledged that staff should have documented whether medications and supplements were given or not. The absence of documentation included missing signatures and lack of evidence for administration or omission of medications, contrary to facility policy and accepted standards for maintaining resident medical records.
Failure to Monitor and Evaluate Coffee Temperature Compliance
Penalty
Summary
The QAPI committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identifying the need to monitor coffee temperatures. The facility's QAPI policy required systems to monitor care and services, including the use of performance indicators to track care processes and outcomes. An in-service training instructed staff to serve coffee at temperatures between 120 to 140 degrees Fahrenheit. However, audit documentation showed that on one occasion, coffee was served at 149.1 degrees Fahrenheit, which was outside the specified range, and no corrective action was documented. Interviews with the Dietary Manager and the DON confirmed that while coffee temperatures were being recorded and audit forms were placed in the QAPI binder, there was no staff member assigned to monitor or evaluate the recorded temperatures or the effectiveness of the in-service training. There was no documented evidence that the QAPI committee reviewed or acted upon the audit findings to ensure compliance with the established temperature guidelines.
Failure to Refer Resident with Serious Mental Illness for PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of bipolar disorder, a serious mental illness, was referred to the Louisiana Office of Behavioral Health for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. Review of the resident's clinical record showed an active diagnosis of bipolar disorder since admission, but there was no documented evidence that a PASARR Level II referral had been made. The social worker responsible for initiating such referrals confirmed in an interview that the resident had not been referred for the required evaluation since admission.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
Surveyors found that the facility failed to serve food at an acceptable temperature, as required. Multiple residents residing on Hall a reported that their food was cold or lukewarm. Observations revealed that a staff member transported lunch trays on a tray cart with the door left open, and food on one resident's tray was found to be lukewarm. Temperature checks of the food items showed readings of 103°F for black eyed peas, 107°F for cooked turnip greens, and 99°F for a fried pork fritter, all below the dietary manager's stated expectation of 120°F for served food. The dietary manager acknowledged that lunch trays had exited the kitchen at 11:35AM but had not been served to all residents by 11:51AM, contributing to the food being served at suboptimal temperatures. Multiple residents confirmed through interviews that their lunch was not hot or was served cold.
Deficiencies in Food Storage and Dish Sanitization Procedures
Penalty
Summary
Facility staff failed to ensure proper storage and labeling of frozen food items, as evidenced by an observation of an opened box of okra in the facility's freezer that was not sealed or labeled with an opened date. The facility's policy required that opened boxes of frozen foods be closed, sealed tightly, and dated when opened, but this was not followed. The Dietary Manager confirmed that the bag of okra was not sealed or labeled as required. Additionally, staff did not adhere to the manufacturer's instructions for sanitizing dishware using the 3 compartment sink. The instructions specified that water in the rinse compartment should be at least 110 degrees Fahrenheit, the sanitization compartment at 75 degrees Fahrenheit, and that dishes should be submerged in the sanitization compartment for 45 seconds. However, a cook reported only checking the temperature of the wash compartment and not timing the sanitization soak, and observations confirmed that temperatures and soak times were not properly monitored. The Dietary Manager and Regional Director of Operations provided inconsistent information regarding the required soak time, further indicating a lack of adherence to proper procedures.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
During a wound care procedure for a resident, the wound care nurse sanitized her hands and donned a gown and gloves before beginning the dressing change. After removing the resident's right foot dressing and disposing of it in a biohazard bag, the nurse removed her gloves and immediately put on a new pair without performing hand hygiene. This process was repeated after cleaning the wound with normal saline, as the nurse again changed gloves without sanitizing her hands in between. Interviews with the wound care nurse, the infection preventionist, and the director of nursing confirmed that hand hygiene should have been performed between glove changes during the dressing change. The facility's policies on universal precautions and handwashing technique require handwashing before and after each resident contact and during duties such as handling dressings, regardless of glove use. The failure to perform hand hygiene between glove changes was observed and acknowledged by staff.
Missing Privacy Curtain in Semi-Private Room
Penalty
Summary
A deficiency was identified when a resident in a semi-private room was observed on two separate occasions to lack a ceiling-suspended privacy curtain around their bed, as required to ensure privacy. During interviews, a Certified Nursing Assistant confirmed that the resident was sharing the room with a roommate and acknowledged that the privacy curtain was missing and should not have been. The facility administrator also confirmed that a privacy curtain is required for residents in semi-private rooms and acknowledged the absence of the curtain for this resident.
Failure to Follow Lift Procedures Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident during a transfer using a mechanical lift, resulting in a serious accident. The staff did not follow the manufacturer's guidelines for the [NAME]-Lift, which required inspecting the sling for damage and leaving the lift's brakes unlocked during transfers. On the day of the incident, the CNA did not inspect the sling, which was already positioned under the resident, and proceeded with the transfer with the lift's brakes locked. This led to the sling's straps breaking, causing the resident to fall and sustain a left temporoparietal subarachnoid hemorrhage. The resident involved in the incident had been admitted to the facility with diagnoses of Down syndrome and Alzheimer's disease. During the transfer, the resident fell from the lift when the sling's straps broke, resulting in a fall that caused a head injury. The resident was subsequently sent to the hospital, where a CT scan confirmed the presence of a subarachnoid hemorrhage. Interviews with the CNAs involved revealed that they were unaware of the requirement to inspect the sling and to leave the brakes unlocked, which contributed to the accident. Additionally, the facility failed to properly launder the lift slings according to the manufacturer's instructions. The slings were dried in a facility dryer that did not have a delicate cycle, contrary to the guidelines that required either a delicate cycle or air drying. The Housekeeping/Laundry Supervisor was unaware of these guidelines, indicating a lack of communication and training regarding the proper care of the lift slings. This oversight could have contributed to the weakening of the sling, leading to the incident.
Deficient Training and Competency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that its staff, specifically a Certified Nursing Assistant (CNA), was trained and deemed competent to transfer a resident using a mechanical lift according to the manufacturer's guidelines. This deficiency was highlighted when a resident was transferred using the lift, and the CNA did not inspect the lift sling properly before use. The CNA also locked the brakes of the lift, contrary to the manufacturer's instructions, which required the brakes to remain unlocked to maintain stability during the transfer. During the transfer, the straps of the lift sling broke, causing the resident to fall to the floor. As a result, the resident sustained a left temporoparietal subarachnoid hemorrhage, a serious injury involving bleeding in the brain. The incident was reported, and it was found that the CNA had not been evaluated for competency in using the lift, and the CNA Supervisor was unaware of the correct procedure for using the lift, including the requirement to leave the brakes unlocked. Interviews with staff revealed a lack of proper training and competency evaluation for using the mechanical lift. The CNA Supervisor, along with the Director of Nursing and Assistant Director of Nursing, were responsible for training staff but did not follow the manufacturer's guidelines. The facility was unable to provide documented evidence of the CNA's competency evaluation, and the Administrator acknowledged awareness of the correct procedure but did not offer further explanation for the deficiency.
Deficient Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to a serious incident involving a resident. The staff did not follow the facility's policy for transferring a resident using a mechanical lift, known as the [NAME]-Lift. Specifically, the staff did not inspect the entire sling for damage before use and failed to unlock the lift's brakes during the transfer. This oversight resulted in the sling's straps breaking, causing the resident to fall and sustain a left temporoparietal subarachnoid hemorrhage, necessitating emergency medical attention. Additionally, the facility lacked a proper system to ensure the laundering of the [NAME]-Lift slings according to the manufacturer's guidelines. The Housekeeping/Laundry Supervisor was unaware of these guidelines, and the facility's dryer did not have a delicate cycle, which could compromise the integrity of the slings. Furthermore, there was no documented evidence that staff, including the CNA involved, were evaluated and deemed competent in using the [NAME]-Lift, highlighting a significant gap in staff training and competency assurance.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment that addressed all necessary components for competent resident care during both routine operations and emergencies. The assessment, dated and reviewed on 06/14/2024, was found lacking in several critical areas, including staff competencies, the physical environment and equipment, ethnic, cultural, or religious factors, and the facility's resources. During an interview on 06/26/2024, the Regional Director of Operations acknowledged that the facility had not completed Section 3 of the assessment, which was supposed to cover these missing components. This oversight resulted in the facility-wide assessment being incomplete and not meeting the required standards.
Lack of Required Training on Resident Rights for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required training on resident rights and facility responsibilities. This deficiency was identified through interviews and record reviews, which revealed that seven CNAs, including a CNA Supervisor, did not have documented evidence of completing the necessary training. The personnel records of these staff members, hired between 2014 and 2023, lacked documentation of the required training on resident rights and facility responsibilities. During an interview, the facility's administrator acknowledged the absence of documented evidence for the required training for the mentioned staff members. This lack of documentation indicates that the facility did not comply with the training requirements necessary to ensure proper care for its residents, as mandated by regulations.
Failure to Invite Cognitively Intact Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two residents, who were cognitively intact, were able to participate in their care plan meetings. Resident #32, with a BIMS score of 15, indicating cognitive intactness, was not invited to care plan meetings on three occasions as evidenced by the absence of a time noted next to her name on the facility's list of care plan meetings. In an interview, Resident #32 confirmed that she had never been invited to a care plan meeting and expressed willingness to attend if invited. Similarly, Resident #46, also with a BIMS score of 15, was not invited to care plan meetings on three separate occasions. The facility's list of care plan meetings showed no time noted next to Resident #46's name, and in an interview, she confirmed not being invited to any care plan meetings. The facility's social services staff indicated that the interdisciplinary team met with residents individually before the care plan meetings and then met without the residents to review the care plans. However, there was no documented evidence that either resident was invited to participate in their care plan meetings.
Failure to Conduct CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance reviews and provide training based on performance evaluation outcomes for several Certified Nursing Assistants (CNAs) and a CNA Supervisor. The personnel records of seven CNAs and their supervisor were reviewed, revealing a lack of documented evidence of yearly performance evaluations or training. The CNAs in question were hired between 2016 and 2023, yet none had received the required evaluations or subsequent training. Interviews conducted with the CNA Supervisor and the facility's Administrator confirmed the absence of performance evaluations for the CNA staff. The CNA Supervisor admitted to not completing evaluations for the CNAs under her supervision. Additionally, the Administrator acknowledged conducting evaluations for certain staff but not for the CNA staff, indicating a systemic oversight in the facility's performance review process for this group of employees.
Inaccurate Blood Glucose Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding blood glucose levels. Resident #32 had a physician's order to receive Novolog, a diabetes medication, based on a sliding scale. However, the electronic Medication Administration Record (eMAR) for June 2024 showed discrepancies. On June 17, 2024, the resident was administered 3 units of Novolog for a blood glucose level of 173, but there was also an instance where no units were administered despite the blood glucose being documented as 'high.' Additionally, there was no documentation of blood glucose levels on June 9, 2024. During an interview, the Assistant Director of Nursing acknowledged the inaccuracies in the eMAR and stated that nurses should document actual blood glucose levels instead of using vague terms like 'high.'
Failure to Train CNAs on QAPI Requirements
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff were trained on the requirements for the Quality Assurance Performance Improvement (QAPI) program. This deficiency was identified through interviews and record reviews, which revealed that seven CNAs, including a CNA Supervisor, did not have documented evidence of receiving the required QAPI training. The personnel records of these staff members, hired between 2014 and 2023, lacked documentation of training on the elements and goals of the facility's QAPI program. During an interview, the facility's administrator admitted the inability to produce documented evidence of the required QAPI training for the mentioned staff. This lack of documentation indicates a failure in the facility's responsibility to ensure that all staff are adequately trained in the QAPI program, which is essential for maintaining and improving the quality of care provided to residents.
Inadequate Infection Control Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff were adequately trained on an infection control system designed to prevent, identify, report, investigate, and control infections and communicable diseases. This deficiency was identified through interviews and record reviews, which revealed that none of the seven personnel records reviewed contained documented evidence of such training. The CNAs in question, including a CNA Supervisor, were hired between 2014 and 2023, yet there was no documentation to confirm that they had received the necessary infection control training. During an interview, the facility's administrator admitted the inability to produce documented evidence of the required infection control training for the staff members mentioned. This lack of documentation indicates a systemic failure in the facility's infection prevention and control program, as it did not include mandatory training with written standards, policies, and procedures for infection control. The absence of this critical training could potentially compromise the facility's ability to manage infections and communicable diseases effectively.
Lack of Compliance and Ethics Training for CNA Staff
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff were trained on the requirements for Compliance and Ethics. This deficiency was identified for seven staff members, including six CNAs and one CNA Supervisor. The personnel records of these staff members, hired between 2014 and 2023, lacked documented evidence of training on compliance and ethics as required by regulations. The absence of such documentation was confirmed through interviews and record reviews. During an interview, the facility's administrator acknowledged the inability to produce documented evidence of the required training for the mentioned staff. This lack of documentation indicates that the facility did not fulfill its obligation to train its staff on compliance and ethics, which is a critical component of maintaining regulatory standards and ensuring ethical practices within the facility.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light button was within reach, as required by the resident's care plan. The care plan for the resident, who is bed-bound, specified that the call light button should be accessible to the resident. However, observations on multiple occasions revealed that the call light button was placed at the base of the bed or at the resident's feet, making it unreachable. Interviews with Certified Nursing Assistants (CNAs) confirmed that the call light button should not have been positioned at the resident's feet and should have been within reach. The Assistant Director of Nursing also acknowledged that the call light button should be accessible to the resident.
Failure to Update Resident's Code Status in EMR
Penalty
Summary
The facility failed to ensure that a resident's code status was consistent with their wishes, as documented in their advance directive. Resident #86, who was admitted with diagnoses of aphasia and dementia, had an advance directive indicating that Cardiopulmonary Resuscitation (CPR) should not be performed. However, a review of the resident's Electronic Medical Record (EMR) showed that the Advanced Directives tab incorrectly listed the resident as requiring CPR, and the Physician's Orders had an active order to initiate CPR. Interviews revealed that the Licensed Practical Nurse (LPN) Medicare Nurse Manager was notified of the change in the resident's code status to Do Not Resuscitate (DNR) by Social Services but did not update the EMR until a later date. The LPN acknowledged the importance of ensuring that a resident's code status in their EMR matches their advance directive to ensure the resident's wishes are followed. The facility's administrator confirmed that the code status should have been updated promptly.
Improper Catheter Care and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper sanitary care for residents with urinary catheters, leading to deficiencies in the care of two residents. Resident #16 was observed with a catheter bag placed on the floor, which was confirmed by both the Staff Development Nurse and the Infection Preventionist as inappropriate and unsanitary. This improper placement of the catheter bag could potentially lead to contamination and infection. Resident #76, who had a history of urinary tract infections, received improper catheter care from a Certified Nursing Assistant (CNA). The CNA used two wash basins, one with soapy water and one with clean rinsing water, but contaminated the rinsing water by placing used towels into it. The CNA then used the contaminated rinsing water to clean the resident's perineal and catheter area, which was acknowledged as incorrect by both the CNA and the Assistant Director of Nursing. This improper procedure could compromise the resident's health by increasing the risk of infection.
Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to ensure that soiled linen was bagged or contained in a sanitary manner at the location where it was collected. This deficiency was observed in the case of one resident, where soiled linens were found on the floor of the resident's room, accompanied by a urine odor. During an interview, the resident expressed dissatisfaction with the presence of soiled linen on the floor and indicated a need for someone to remove them. A Certified Nursing Assistant (CNA) confirmed that the soiled linen should not have been on the floor. The facility administrator acknowledged the CNA's response but did not provide further explanation regarding the deficient practice.
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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 Gonzales
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gonzales Healthcare Center | 0 mi | — | 0 | 0 |
| Landmark South Nursing & Rehabilitation Center | 8.1 mi | — | 1 | 0 |
| Old Jefferson Community Care Center | 10.1 mi | — | 1 | 0 |
| Chateau D'ville Rehab And Retirement | 10.3 mi | — | 1 | 0 |
| Jefferson Manor Nursing And Rehab Ctr, Llc | 13.3 mi | — | 4 | 0 |
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