Inspection Reports for
Ascension Oaks Nursing & Rehab Center
711 W. CORNERVIEW ROAD, GONZALES, LA, 70737
Back to Facility Profile5 Reports
Inspection Report — Jun 12, 2025
Routine CMS
Date: Jun 12, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, food safety, medication administration, infection control, privacy, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to refer a resident for required PASARR evaluation, serving food at unsafe temperatures, improper food storage and dish sanitization, incomplete medication administration records, inadequate monitoring of coffee temperatures, failure to perform hand hygiene between glove changes during wound care, and lack of privacy curtains in semi-private rooms.
Deficiencies (7)
F 0644: The facility failed to ensure a resident with bipolar disorder was referred to the Louisiana Office of Behavioral Health for a PASARR Level II evaluation as required.
F 0804: The facility failed to serve residents' food at an acceptable temperature; food on a resident's lunch tray was lukewarm and below expected temperature standards.
F 0812: The facility failed to properly contain and label frozen food with an opened date and did not follow manufacturer's instructions for sanitizing dishware using the 3 compartment sink.
F 0842: The facility failed to maintain and accurately document residents' electronic Medication Administration Records for multiple medications for two residents.
F 0865: The facility's QAPI committee failed to provide evidence of monitoring and evaluation of coffee temperatures to ensure corrective actions after identifying temperature issues.
F 0880: The facility failed to ensure staff performed hand hygiene between glove changes during wound care for a resident.
F 0914: The facility failed to provide a ceiling suspended privacy curtain around the bed for a resident in a semi-private room to ensure privacy.
Report Facts
Coffee temperature: 149.1
Food temperatures: 103
Food temperatures: 107
Food temperatures: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S16 Social Worker | Social Worker | Responsible for initiating PASARR referral; confirmed failure to refer Resident #85 |
| S14 Dietary Manager | Dietary Manager | Acknowledged food temperature issues and coffee temperature monitoring responsibilities |
| S15 Cook | Cook | Did not follow manufacturer's instructions for dish sanitization in 3 compartment sink |
| S2 Director of Nursing | Director of Nursing | Confirmed missing medication documentation and lack of monitoring of coffee temperature audits |
| S12 Wound Care Nurse | Wound Care Registered Nurse | Failed to perform hand hygiene between glove changes during wound care |
| S13 Licensed Practical Nurse | Licensed Practical Nurse/Infection Preventionist | Confirmed hand hygiene should have been performed between glove changes |
| S11 Certified Nursing Assistant | Certified Nursing Assistant | Reported missing privacy curtain for Resident #79 |
| S1 Administrator | Administrator | Acknowledged missing privacy curtain for Resident #79 |
Inspection Report — Mar 5, 2024
Complaint Investigation CMS
Date: Mar 5, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall and injury at Ascension Oaks Nursing & Rehab Center.
Complaint Details
The complaint investigation found that Resident #1's wheelchair was removed from her room by a CNA, making it inaccessible and contributing to a fall that caused a left femur fracture. The fall was substantiated with actual harm.
Findings
The facility failed to ensure Resident #1's assistive device (wheelchair) was available, resulting in a fall on 02/21/2024 that caused a left femur fracture requiring hospitalization and surgical repair. The resident experienced a decline in functional mobility and continence due to the fall and injury.
Deficiencies (1)
F 0689: The facility failed to keep Resident #1's assistive device within reach, leading to a fall and left femur fracture on 02/21/2024. This resulted in actual harm and a decline in the resident's functional abilities.
Report Facts
Date of fall: Feb 21, 2024
Date of fracture diagnosis: Feb 22, 2024
Fall risk assessment score: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Removed Resident #1's wheelchair from her room | |
| Licensed Practical Nurse (LPN) | Observed Resident #1 using wheelchair as a walker prior to fall | |
| Director of Nursing (DON) | Confirmed care plan and removal of wheelchair was inappropriate |
Inspection Report — Aug 17, 2023
Complaint Investigation CMS
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident-to-resident physical abuse, failure to timely report suspected abuse, and inadequate investigation of alleged abuse incidents.
Complaint Details
The complaint investigation focused on allegations of resident-to-resident physical abuse involving Residents #9, #20, #29, and #65. The facility failed to protect residents from abuse, failed to timely report incidents to the State Survey Agency, and failed to thoroughly investigate the incidents as required.
Findings
The facility failed to protect residents from physical abuse by other residents, failed to timely report two incidents of suspected abuse to the State Survey Agency, and failed to thoroughly investigate an alleged incident of abuse. Additionally, the facility had multiple safety hazards including unsecured oxygen cylinders, unlocked electrical and housekeeping closets, expired medications, and food safety violations in the kitchen.
Deficiencies (6)
F 0600: The facility failed to protect residents from resident-to-resident physical abuse involving Residents #20, #29, #9, and #65, with incidents occurring on 07/19/2023 and 07/28/2023.
F 0609: The facility failed to timely report two incidents of suspected physical abuse to the State Survey Agency as required by regulations.
F 0610: The facility failed to thoroughly investigate an alleged incident of resident-to-resident physical abuse involving Resident #20 and Resident #29, lacking documentation and interviews.
F 0689: The facility failed to ensure safety by leaving kitchen doors unlocked allowing a wandering resident to enter, unsecured oxygen cylinders in a lounge, and unlocked electrical and housekeeping closets containing hazardous materials accessible to residents.
F 0761: The facility failed to ensure expired medications were removed from a treatment cart, including DermaSyn/Ag Silver Antibacterial Wound Gel, Gentian solution, and Povidone Iodine.
F 0812: The facility failed to properly label and date foods in the kitchen's walk-in refrigerator, maintain dishwasher rinse temperatures at or above 120°F, and ensure a fan blowing over resident food was clean.
Report Facts
Residents affected: 4
Residents affected: 96
Expired medications: 3
Dishwasher rinse temperature: 110
Dishwasher required rinse temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Reviewed surveillance footage and made determinations regarding abuse incidents and reporting. |
| S2 Director of Nursing | Director of Nursing | Confirmed expired medications and commented on oxygen cylinder storage and QA coverage. |
| S3 Assistant Director of Nursing | Assistant Director of Nursing | Interviewed residents involved in abuse incidents. |
| S7 Licensed Practical Nurse | Licensed Practical Nurse | Witnessed Resident #20 hitting Resident #29 and documented nurse's notes. |
| S10 Dietary Manager | Dietary Manager | Reported on kitchen food labeling, dishwasher temperature, and fan cleanliness. |
| S14 Licensed Practical Nurse | Licensed Practical Nurse | Provided statements regarding abuse incidents and resident behaviors. |
Inspection Report — Jul 19, 2023
CMS
Date: Jul 19, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with staffing requirements, specifically ensuring the presence of a registered nurse on duty for eight consecutive hours per day.
Findings
The facility failed to ensure eight consecutive hours per day of registered nurse coverage for 2 of 25 weekend staffing hours reviewed, with no documented evidence of RN coverage or waiver for the dates 02/04/2023 and 03/26/2023. The administrator confirmed the lack of required RN staffing on those days.
Deficiencies (1)
F 0727: The facility failed to have a registered nurse on duty for eight consecutive hours on 02/04/2023 and 03/26/2023 as required. There was no documented evidence or waiver for RN coverage on these dates.
Report Facts
Weekend staffing hours reviewed: 25
Weekend staffing hours without RN coverage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed the facility did not provide required RN staffing hours on the specified dates |
Inspection Report — Sep 9, 2022
Annual Inspection CMS
Date: Sep 9, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and ensure resident safety and care quality at Ascension Oaks Nursing & Rehab Center.
Findings
The facility was found deficient in protecting residents from abuse, applying physician-ordered treatments, ensuring safety for unsafe smokers, and maintaining proper food storage and sanitation standards. Several residents were affected by these deficiencies, with issues ranging from physical abuse to failure to apply splints and inadequate monitoring of kitchen equipment.
Deficiencies (4)
F 0600: The facility failed to protect Resident #46 from physical abuse by a staff member who grabbed and shoved the resident, resulting in bruising. The staff member was terminated following substantiated abuse.
F 0688: The facility failed to apply a physician-ordered left hand splint for Resident #14, who had hemiplegia and impaired range of motion, resulting in lack of proper supportive care.
F 0689: The facility failed to ensure Resident #71, an unsafe smoker with visual impairment, wore a smoking apron and was supervised while smoking, increasing risk of injury.
F 0812: The facility failed to monitor walk-in cooler and freezer temperatures, maintain dishwasher sanitizer levels, and ensure dishwasher operating temperatures met policy, risking food safety for residents.
Report Facts
Residents sampled: 25
Residents investigated for range of motion: 35
Residents identified as having contractures: 25
Residents who smoke: 9
Residents affected by food safety deficiencies: 101
Dishwasher sanitizer ppm observed: 10
Dishwasher operating temperature observed: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Reviewed video recordings and confirmed abuse by housekeeper |
| S7 Housekeeper | Housekeeper | Terminated for physical abuse of Resident #46 |
| S2 Director of Nursing | Director of Nursing | Acknowledged abuse and failure to apply splint; confirmed smoking supervision requirements |
| S8 LPN | Licensed Practical Nurse | Unable to verify daily use of splint for Resident #14 |
| S7 CNA | Certified Nurse Assistant | Acknowledged Resident #14 had not received restorative services |
| S9 CNA | Certified Nurse Assistant | Acknowledged Resident #14 had not received restorative services |
| S5 Clinical Care Coordinator | Clinical Care Coordinator | Acknowledged Resident #71 was an unsafe smoker needing supervision and smoking apron |
| S4 Dietary Manager | Dietary Manager | Reported issues with temperature monitoring and dishwasher sanitizer levels |
| S4 Cook | Cook | Reported dishwasher operating temperature observations |
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