Inspection Reports for
Oak Haven Rehabilitation and Healthcare Center
1515 HIGHWAY 107, CENTER POINT, LA, 71323
Back to Facility Profile8 Reports
Inspection Report — Dec 3, 2025
Routine CMS
Date: Dec 3, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in services provided by the nursing facility, including dietary and food service operations.
Findings
The facility failed to ensure that a resident received ordered dietary supplements, dietary staff were inadequately trained to safely and effectively perform food service functions, pureed food was not prepared according to approved recipes, and food safety monitoring such as temperature logs and hair restraints were not properly maintained.
Deficiencies (4)
F 0658: The facility failed to ensure Resident #4 received the ordered 4 ounces of ice cream daily with lunch as a nutritional intervention.
F 0802: Dietary support personnel were not competent to safely and effectively perform food and nutrition service functions, including lack of training on dishwashing, food preparation, and temperature monitoring.
F 0804: Pureed food was not prepared using approved recipes or measurements, compromising nutritional adequacy for 7 residents on a puree diet.
F 0812: The facility failed to maintain a clean and sanitary kitchen and did not properly monitor or log dishwasher, cooler, freezer, and food temperatures, and dietary staff did not wear required hair restraints.
Report Facts
Residents affected: 1
Residents affected: 7
Residents affected: 89
Weight measurements: 131
Weight measurements: 143
Facial hair length: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6Dietary | Dietary Aide | Not trained on dishwashing and food safety; observed not wearing facial hair covering |
| S5Dietary | Cook | Not trained on dishwashing, food temperature checks, and recipe adherence |
| S4Cook | Cook | Did not follow recipes when preparing pureed food |
| S3DM | Dietary Manager | Confirmed lack of training and monitoring of food safety logs |
| S7Cook | Cook | Does not follow recipes when preparing pureed food |
| S1Administrator | Administrator | Acknowledged high kitchen staff turnover and lack of training |
Inspection Report — May 7, 2025
Routine CMS
Date: May 7, 2025
Visit Reason
Routine inspection of Oak Haven Rehabilitation and Healthcare Center to assess compliance with regulatory standards including resident rights, care planning, medication administration, infection control, and facility sanitation.
Findings
The facility had multiple deficiencies including failure to promptly address resident grievances, inaccurate medical record documentation, incomplete care plan implementation, improper medication administration, inadequate communication aids, unsanitary kitchen conditions, improper disposal of refuse, incomplete infection prevention practices, and inaccurate infection surveillance reporting.
Deficiencies (13)
F 0565: The facility failed to act promptly on grievances voiced by residents during monthly Resident Council meetings regarding CNAs talking loudly and not offering meal choices.
F 0578: The facility failed to ensure Resident #4's advance directive was properly reflected in medical records, resulting in inconsistent documentation of DNI status.
F 0641: The facility failed to ensure the Minimum Data Set assessment accurately reflected Resident #68's hearing difficulties.
F 0656: The facility failed to implement the person-centered care plan for Residents #13 and #76, including lack of anticoagulant monitoring and improper fall mat placement.
F 0658: The facility failed to position Resident #41 properly during administration of breathing treatment, contrary to manufacturer instructions.
F 0676: The facility failed to provide a communication board for Resident #26, impairing her ability to communicate effectively.
F 0685: The facility failed to assist Resident #68 in gaining access to hearing services, including audiology evaluation and hearing aids.
F 0688: The facility failed to provide restorative therapy and range of motion exercises as care planned for Resident #80, risking further decline.
F 0761: Controlled medications were not stored in separately locked compartments in Medication Room A due to a lockbox key issue.
F 0812: The facility failed to maintain a clean and sanitary kitchen, with expired, unsealed, and undated food items and staff not wearing hair/beard restraints.
F 0814: The facility failed to properly dispose of garbage and refuse, with debris and waste scattered around the dumpster area.
F 0868: The facility failed to include the Administrator or designee in the Quality Assessment and Assurance Process Quarterly meetings for three consecutive months.
F 0880: The facility failed to maintain an effective infection prevention and control program, including staff not wearing masks during a COVID outbreak, improper wound care practices, and inaccurate infection surveillance reporting.
Report Facts
Sample size: 29
MDRO infections: 4
MDRO infections: 7
MDRO infections: 3
MDRO infections: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Confirmed awareness of resident complaints and infection control policies |
| S2 DON | Director of Nursing | Confirmed deficiencies in care plan implementation and medication monitoring |
| S3 Dietary Manager | Dietary Manager | Confirmed kitchen sanitation and dumpster area deficiencies |
| S5 LPN | Licensed Practical Nurse | Observed improper medication storage and improper positioning during treatment |
| S8 RN | Registered Nurse | Confirmed lack of anticoagulant monitoring for Resident #13 |
| S9 Director of Rehab Services | Director of Rehabilitation Services | Confirmed lack of restorative therapy for Resident #80 |
| S11 Cook | Cook | Observed not wearing hair/beard restraint during meal preparation |
| S12 CNA | Certified Nursing Assistant | Observed not wearing mask during COVID outbreak |
| S13 LPN | Licensed Practical Nurse | Confirmed communication board deficiency and fall mat placement issues |
| S14 Treatment Nurse | Treatment Nurse | Observed improper wound care infection control practices |
| S15 Charge Nurse | Charge Nurse | Confirmed mask policy and resident communication board issues |
| S16 CNA Supervisor | CNA Supervisor | Confirmed communication board deficiency for Resident #26 |
| S17 Activities Director | Activities Director | Confirmed resident hearing difficulties and unresolved complaints |
| S18 MDS | MDS Coordinator | Confirmed inaccurate MDS hearing assessment for Resident #68 |
| S19 Infection Preventionist | Infection Preventionist | Confirmed inaccurate infection surveillance reporting |
| S23 Social Services Director | Social Services Director | Confirmed failure to schedule audiology evaluation for Resident #68 |
Inspection Report — Feb 5, 2025
CMS
Date: Feb 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, care planning, and infection control at Oak Haven Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in maintaining a clean and homelike environment for a legally blind resident after a room change, failing to develop and implement a person-centered care plan addressing smoking for a resident, and failing to ensure proper hand hygiene during wound care for another resident.
Deficiencies (3)
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment by not providing an uncluttered, neat, and well-kept room for Resident #2, who is legally blind and had difficulty finding her belongings after a room change.
F 0656: The facility failed to develop and implement a complete care plan for Resident #1 that included smoking and appropriate nursing interventions despite the resident being a smoker.
F 0880: The facility failed to maintain an infection prevention and control program by not ensuring staff performed hand hygiene before and after wound care for Resident #3.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 DON | Director of Nursing | Confirmed Resident #1 smoked and that a care plan had not been developed for smoking interventions; confirmed hand hygiene expectations for wound care. |
| S4 RN Treatment Nurse | RN Treatment Nurse | Observed failing to perform hand hygiene before and after wound care for Resident #3. |
Inspection Report — Dec 5, 2024
Complaint Investigation CMS
Date: Dec 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure proper care planning and supervision for residents requiring extensive assistance, specifically related to falls and ADL care.
Complaint Details
The complaint investigation substantiated that Resident #1 required two-person extensive assistance for bed mobility and ADLs. The failure to follow this care plan resulted in a fall on 11/07/2024 causing a right hip fracture. Staff interviews confirmed lack of adherence to care plan and signage protocols.
Findings
The facility failed to ensure Resident #1's comprehensive care plan included required two-person extensive assistance for bed mobility, turning, and repositioning. This failure led to Resident #1 falling out of bed during a bed bath, resulting in a right hip fracture. Staff did not follow care plan interventions or use required assistance, causing actual harm.
Deficiencies (2)
F 0657: The facility failed to develop and revise Resident #1's care plan to include two-person extensive assistance for turning, repositioning, and bed mobility as required for fall prevention.
F 0689: The facility failed to provide adequate supervision and two-person assistance for Resident #1 during ADL care, resulting in a fall with major injury and a closed right hip fracture.
Report Facts
Date of fall with injury: Nov 7, 2024
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 CNA | Certified Nursing Assistant | Provided care alone to Resident #1 during bed bath when fall occurred; failed to follow two-person assistance protocol. |
| S2 ADON | Assistant Director of Nursing | Confirmed Resident #1 required two-person assistance and acknowledged care plan was not updated accordingly. |
| S3 LPN | Licensed Practical Nurse | Responded to fall incident and confirmed care plan requirements for two-person assistance. |
| S7 FNP | Family Nurse Practitioner | Assessed Resident #1 after fall and arranged hospital evaluation. |
| S1 DON | Director of Nursing | Confirmed Resident #1's fracture and that two-person assistance was required but not provided. |
Inspection Report — Mar 21, 2024
Routine CMS
Date: Mar 21, 2024
Visit Reason
Routine inspection of Oak Haven Rehabilitation and Healthcare Center to assess compliance with regulatory standards related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure dignity for cognitively impaired residents, failure to notify physicians of significant changes, failure to provide CPR per advanced directives, improper respiratory and medication storage practices, and improper food preparation methods.
Deficiencies (7)
F 0550: The facility failed to ensure Resident #68 was treated with dignity by placing her within sight of the dining area during meal service despite being NPO and tube fed.
F 0580: The facility failed to immediately notify Resident #76's physician of a significant change in condition and death.
F 0658: The facility failed to replace the tube feeding syringe and label the flush set bag for Resident #68 receiving enteral tube feedings.
F 0678: The facility failed to provide CPR to Resident #76 who was a full code and found unresponsive without a pulse, resulting in immediate jeopardy.
F 0695: The facility failed to ensure respiratory equipment for Resident #31 was properly changed, labeled, and stored.
F 0761: The facility failed to store all drugs and biologicals in locked compartments as required, evidenced by an unlocked medication cart.
F 0804: The facility failed to prepare pureed foods according to approved recipes, using unmeasured tap water which disrupted nutritional value for 5 residents.
Report Facts
Residents reviewed: 23
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts inspected: 4
Medication carts unlocked: 1
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 LPN | Licensed Practical Nurse | Failed to initiate CPR on Resident #76 and did not notify EMS or physician |
| S1 Administrator | Administrator | Acknowledged dignity issue with Resident #68 and confirmed CPR certification status of staff |
| S2 DON | Director of Nursing | Confirmed medication cart was unlocked and that S4 LPN should have initiated CPR |
| S9 Dietary Manager | Dietary Manager | Confirmed improper preparation of pureed foods and need to follow recipes |
| S10 RD | Registered Dietitian | Confirmed water should not be used in pureed food preparation |
Inspection Report — Feb 21, 2024
Complaint Investigation CMS
Date: Feb 21, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to promptly resolve grievances filed by a resident's representative and to develop an individualized care plan addressing aggressive behaviors for a resident.
Complaint Details
The complaint involved Resident #2's spouse raising concerns about repeated positive tests for Escherichia Coli in the resident's urine and the facility's failure to address or document these concerns through a grievance process. The complaint was substantiated by interviews and record reviews.
Findings
The facility failed to promptly investigate and resolve grievances related to a resident's repeated urinary tract infections and did not develop a care plan addressing aggressive behaviors for the resident. Interviews revealed staff did not document or initiate grievance procedures despite concerns raised by the resident's spouse.
Deficiencies (2)
F 0585: The facility failed to make a prompt effort to resolve grievances filed by a resident's representative and submit a report of findings for 1 of 3 sampled residents.
F 0656: The facility failed to develop and implement a complete care plan addressing aggressive behaviors for 1 of 3 sampled residents.
Report Facts
Residents sampled: 3
Residents affected: 1
BIMS score: 5
Length of phone conversation: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Spoke with Resident #2's spouse regarding concerns and did not initiate grievance |
| S2 DON | Director of Nursing | Spoke with Resident #2's spouse and confirmed no grievance was initiated |
| S3 Corporate Regional Director | Corporate Regional Director | Contacted Resident #2's spouse and acknowledged grievance was not done |
Inspection Report — May 31, 2023
Complaint Investigation CMS
Date: May 31, 2023
Visit Reason
The inspection was conducted following complaints regarding misappropriation of resident property and failure to provide appropriate treatment and services to residents with dementia.
Complaint Details
The complaint investigation substantiated misappropriation of medications by a staff nurse and inadequate care planning for a resident with dementia exhibiting sexual behaviors.
Findings
The facility failed to protect residents from misappropriation of medications by a staff nurse affecting three residents. Additionally, the facility failed to develop and implement a person-centered care plan for a resident exhibiting new onset sexual behaviors related to dementia.
Deficiencies (2)
F 0602: The facility failed to ensure a resident was free from misappropriation of property for 3 of 5 residents reviewed for abuse. A staff nurse admitted to taking Hydrocodone doses from residents without administering them.
F 0744: The facility failed to provide appropriate treatment and services to a resident with dementia by not updating the care plan or notifying psychiatric services about new sexual behaviors exhibited by the resident.
Report Facts
Residents reviewed for abuse: 5
Residents affected by misappropriation: 3
Doses of Hydrocodone taken: 3
Assessment Reference Date: Apr 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 LPN | Staff nurse who admitted to taking Hydrocodone doses | |
| S2 ADON | Assistant Director of Nursing involved in interviews and confirmation of findings | |
| S3 APRN | Psychiatric provider who completed evaluations and was unaware of new sexual behaviors | |
| S6 LPN | Nurse who noticed irregularities in narcotic counts | |
| S5 LPN | Nurse who assisted in reviewing narcotic blister packs |
Inspection Report — Mar 1, 2023
Routine CMS
Date: Mar 1, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements related to resident care, staffing, medication management, food service, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to develop and implement policies for screening agency staff, failure to post nurse staffing information accessibly, inaccurate controlled medication reconciliation, serving food at unsafe temperatures, and failure to follow hand hygiene protocols during food service.
Deficiencies (5)
F 0607: The facility failed to develop and implement written policies and procedures to protect residents from abuse, neglect, exploitation, and misappropriation by not screening agency staff's background prior to allowing unlicensed agency CNAs to work.
F 0732: The facility failed to post nurse staffing information daily in a place readily accessible to residents and visitors as required.
F 0755: The facility failed to ensure accurate accounting and reconciliation of controlled medications for one medication cart, with discrepancies noted in narcotic counts and shift change reconciliations.
F 0804: The facility failed to provide food at safe and appetizing temperatures to residents, with multiple observations of cold food and open insulated food cart doors during meal service.
F 0812: The facility failed to serve food in accordance with professional standards by not sanitizing or washing hands between passing food trays to residents in the dining room.
Report Facts
Residents affected: 16
Medication pills discrepancy: 2
Residents with cold food: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 ADM | Administrator | Confirmed lack of written policy for agency staff background checks and staffing posting issues. |
| S2 DON | Director of Nursing | Interviewed regarding nurse staffing posting and hand hygiene during food service. |
| S4 ADM Assistant | Assistant Administrator | Responsible for posting nurse staffing information. |
| S5 DM | Dietary Manager | Confirmed food temperature policy and observed cold food temperatures. |
| S11 LPN | Licensed Practical Nurse | Interviewed about medication reconciliation discrepancies. |
| S3 ADON | Assistant Director of Nursing | Confirmed narcotic count procedures and discrepancies. |
| S9 CNA | Certified Nursing Assistant | Observed leaving insulated food cart door open during meal delivery. |
| S6 Dietary | Dietary Staff | Observed not sanitizing or washing hands between passing food trays. |
Viewing
Loading inspection reports...
