Inspection Reports for
Twin Oaks Nursing Home
506 WEST 5TH STREET, LAPLACE, LA, 70068
Back to Facility Profile11 Reports
Inspection Report — Jan 15, 2026
Complaint Investigation CMS
Date: Jan 15, 2026
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an injury of unknown origin with serious bodily injury to the State Survey Agency.
Complaint Details
The complaint investigation found that the facility did not timely report an injury of unknown origin with serious bodily injury for Resident #1. The injury was reported late on 12/16/2025, although the injury was noted earlier. The facility staff determined the injury was not of unknown origin due to osteoporosis and did not suspect abuse, leading to the delayed report.
Findings
The facility failed to report an injury of unknown origin involving Resident #1 within the required two-hour timeframe. The injury was later determined by facility staff not to be of unknown origin due to Resident #1's osteoporosis diagnosis, and thus was not reported timely as required.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and the results of the investigation to proper authorities. Resident #1's injury of unknown origin with serious bodily injury was not reported to the State Survey Agency within two hours as required.
Report Facts
Incident report number: 316731
Assessment Reference Date: 12092025
Radiology report date: 12112025
Survey completion date: Jan 15, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Notified of Resident #1's injury and determined it was not of unknown origin | |
| Director of Nursing | Determined Resident #1's injury was not of unknown origin and did not suspect abuse | |
| Nurse Practitioner | Notified of Resident #1's complaint of pain and ordered x-ray |
Inspection Report — Aug 13, 2025
Annual Inspection CMS
Date: Aug 13, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements across multiple areas including resident environment, respiratory care, nutrition, food safety, infection control, and catheter care.
Findings
The facility was found deficient in maintaining a clean and odor-free environment in a resident's room, ensuring timely change of respiratory nebulizer tubing, documenting and approving menu substitutions, proper food storage and labeling, use of unexpired sanitization test strips, and adherence to infection prevention protocols including appropriate use of personal protective equipment (PPE).
Deficiencies (5)
F 0584: The facility failed to maintain Resident #56's room free of odors, soiled linens, spills, and debris, compromising a safe and homelike environment.
F 0695: The facility failed to ensure respiratory nebulizer tubing for Resident #22 was changed and dated weekly as ordered, with tubing last changed on 07/07/2025.
F 0803: The facility failed to ensure menu substitutions were approved by the dietician, with undocumented substitution of beets for brussel sprouts on 08/11/2025.
F 0812: The facility failed to label and date food items once opened, cover food items in the refrigerator, label outside food sources in the freezer, and used expired sanitization test strips for the dishwasher.
F 0880: The facility failed to ensure staff wore appropriate PPE when moving a mattress in Resident #90's room on contact isolation and when providing care to Resident #4 on Enhanced Barrier Precautions.
Report Facts
Residents sampled for environment: 7
Residents sampled for respiratory care: 8
Residents sampled for infection control: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 | Director of Nursing | Acknowledged findings related to Resident #56's room odor and Resident #22's nebulizer tubing not changed weekly; confirmed PPE use requirements. |
| S7 | Certified Nursing Assistant | Confirmed presence of odor, soiled linens, spill, and debris in Resident #56's room. |
| S12 | Dietary Manager | Indicated lack of documentation and notification to Registered Dietician for menu substitution and food labeling issues. |
| S19 | Registered Dietician | Confirmed no notification of menu substitution on 08/11/2025. |
| S10 | Maintenance | Moved Resident #90's mattress without wearing required gown and gloves. |
| S11 | Assistant Director of Nursing | Confirmed PPE violations by Maintenance staff in Resident #90's room. |
| S16 | Certified Nursing Assistant | Failed to wear gown while draining Resident #4's urine collection bag and emptying output container. |
| S20 | Licensed Practical Nurse/Infection Preventionist | Provided information on Enhanced Barrier Precautions and PPE requirements. |
Inspection Report — Apr 30, 2025
Annual Inspection CMS
Date: Apr 30, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident rights, abuse reporting, discharge notifications, PASARR evaluations, and facility-wide assessments.
Findings
The facility failed to protect a resident from resident-to-resident physical abuse, failed to timely report suspected abuse to the state incident management system, failed to notify the State's Long-Term Care Ombudsman of resident discharges, failed to complete required PASARR Level II screening after a new diagnosis, and failed to ensure the facility-wide assessment addressed behavioral health needs of residents.
Deficiencies (5)
F 0600: The facility failed to protect a resident's right to be free from resident-to-resident physical abuse for 1 of 4 sampled residents. Resident #4 was hit by Resident #2 causing a swollen upper lip.
F 0609: The facility failed to timely report an incident of resident-to-resident abuse to the statewide incident management system for 2 of 4 sampled residents. The administrator did not consider the incident abuse and did not report it.
F 0628: The facility failed to notify the State's Long-Term Care Ombudsman in writing of discharges for 2 of 3 sampled residents. No documented evidence of notification was presented.
F 0644: The facility failed to ensure a resident with a new diagnosis of bipolar disorder was referred for a PASARR Level II evaluation as required for 1 of 3 sampled residents.
F 0838: The facility failed to conduct and document a facility-wide assessment addressing behavioral health needs, staff competencies, and resources necessary for 3 sampled residents with behavioral health needs.
Report Facts
Residents identified with behavioral health needs: 42
Residents sampled for abuse and rights review: 4
Residents sampled for discharge notification review: 3
Residents sampled for PASARR review: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | S4RN assessed Resident #4 after the abuse incident and noted swelling. | |
| Certified Nursing Assistant | S5CNA witnessed Resident #2 hitting Resident #4. | |
| Quality Assurance Nurse | S6QA Nurse investigated the abuse incident but did not consider it abuse. | |
| Administrator | S1Administrator confirmed the incident but did not consider it abuse and confirmed failure to report. | |
| Social Worker | S3Social Worker indicated no referral was made for PASARR Level II screening after new diagnosis. |
Inspection Report — Sep 5, 2024
Complaint Investigation CMS
Date: Sep 5, 2024
Visit Reason
The inspection was conducted due to an allegation of neglect involving Resident #1, focusing on whether the facility conducted a thorough investigation of the neglect claim.
Complaint Details
The complaint investigation was substantiated as the facility did not complete a thorough investigation of the neglect allegation for Resident #1. The facility failed to interview key staff and residents present during the incident and inaccurately reported wound care orders.
Findings
The facility failed to ensure a thorough investigation was completed for the neglect allegation involving Resident #1. The investigation lacked documented evidence of interviews with staff and residents who observed the incident during the lunch meal service on 08/21/2024.
Deficiencies (1)
F 0610: The facility failed to conduct a thorough investigation of an allegation of neglect for Resident #1, including not obtaining statements from all staff and residents who observed the incident during the lunch meal service on 08/21/2024.
Report Facts
Residents reviewed for neglect: 3
Residents affected: 1
Date of neglect incident: Aug 21, 2024
Inspection Report — Aug 7, 2024
Routine CMS
Date: Aug 7, 2024
Visit Reason
Routine inspection of Twin Oaks Nursing Home to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to protect resident confidentiality, incomplete PASARR screening, inadequate assistance with activities of daily living, lack of respiratory care plans, improper medication cart narcotic counts, failure to provide dental services, and lapses in infection prevention and control practices.
Deficiencies (7)
F 0583: The facility failed to protect client confidentiality for 1 resident by posting a sign with personal medical information on the resident's door facing the hallway.
F 0645: The facility failed to ensure a Level 1 PASARR screening was completed correctly for 1 resident, missing a required referral for Level II evaluation.
F 0677: The facility failed to provide nail care for 2 residents, with observations confirming nails extended past tips and care plans indicating need for assistance.
F 0695: The facility failed to develop a plan of care for 1 resident receiving respiratory care by nasal cannula, with no physician orders found.
F 0755: The facility failed to ensure nursing staff signed verification of accurate medication counts at shift changes for 2 medication carts, with multiple undocumented narcotic counts.
F 0791: The facility failed to ensure a resident was referred for dental services despite care plan goals and resident complaints.
F 0880: The facility failed to ensure clean items were stored separately from contaminated laundry and staff failed to wear proper protective equipment and perform hand hygiene during incontinence care for 1 resident.
Report Facts
Residents sampled: 32
Residents reviewed for PASARR: 1
Residents investigated for ADLs: 6
Medication carts reviewed: 2
Residents reviewed for dental services: 3
Clean mop heads observed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S10 Licensed Practical Nurse | Licensed Practical Nurse | Named in confidentiality violation finding regarding Resident #8 |
| S4 Director of Nursing | Director of Nursing | Named in confidentiality violation and nail care findings |
| S3 Social Services | Social Services | Named in PASARR screening and dental services findings |
| S13 Certified Nursing Assistant | Certified Nursing Assistant | Named in nail care deficiency for Resident #28 |
| S6 MedRecords/CNA Supervisor | MedRecords/CNA Supervisor | Named in nail care deficiency for Resident #28 |
| S12 Wound Care Nurse | Wound Care Nurse | Named in nail care deficiency for Resident #28 |
| S5 Assistant Director of Nursing | Assistant Director of Nursing | Named in respiratory care and infection control findings |
| S8 Licensed Practical Nurse | Licensed Practical Nurse | Named in medication cart narcotic count documentation deficiency |
| S9 Licensed Practical Nurse | Licensed Practical Nurse | Named in medication cart narcotic count documentation deficiency |
| S7 Certified Nursing Assistant | Certified Nursing Assistant | Named in infection control deficiency for improper PPE and hand hygiene |
| S1 Administrator | Administrator | Named in dental services deficiency |
| S2 Laundry Supervisor | Laundry Supervisor | Named in infection control deficiency for improper storage of clean mop heads |
Inspection Report — Jun 27, 2024
Complaint Investigation CMS
Date: Jun 27, 2024
Visit Reason
The inspection was conducted due to allegations of verbal and physical abuse involving Resident #1 and to investigate the facility's response to these abuse allegations.
Complaint Details
The complaint investigation involved allegations that the nursing home administrator pushed Resident #1 on 06/03/2024. The facility failed to report this allegation to the state agency and did not investigate the claim. Interviews with the administrator, regional administrator, director of nursing, resident, and responsible party confirmed the failure to report and investigate.
Findings
The facility failed to timely report an allegation of abuse to the state agency, did not conduct a thorough investigation of the abuse allegation, and failed to provide required training to the administrator involved in the incident.
Deficiencies (3)
F 0609: The facility failed to timely report suspected abuse of Resident #1 to the required state survey agency as mandated by policy and regulations.
F 0610: The facility failed to conduct a thorough investigation following an allegation of physical abuse involving Resident #1 by the administrator.
F 0940: The facility failed to implement an effective training program for the administrator on Quality Assurance, behavioral health, ethics, abuse, and resident rights.
Report Facts
Sampled residents investigated for abuse: 3
Sampled personnel files reviewed for training: 6
Personnel file date of hire: 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1Administrator | Named in abuse allegation and training deficiency | |
| S2Regional Administrator | Confirmed failure to report and investigate abuse allegation | |
| S3Director of Nursing | Aware of abuse allegation but did not report to corporate management |
Inspection Report — May 2, 2024
Complaint Investigation CMS
Date: May 2, 2024
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident abuse and to assess the facility's compliance with abuse prevention, reporting, and investigation requirements.
Complaint Details
The complaint investigation focused on allegations of resident-to-resident verbal and physical abuse involving 10 sampled residents. Some incidents were substantiated, others unsubstantiated. The facility failed to report some incidents timely and did not conduct required investigations.
Findings
The facility failed to protect residents from verbal and physical abuse by other residents, failed to timely report some abuse incidents to the State Survey Agency, and failed to conduct thorough investigations following allegations of abuse. Multiple incidents involving several residents were documented and confirmed through interviews and video review.
Deficiencies (3)
F 0600: The facility failed to protect residents from verbal and physical abuse by other residents, affecting 6 of 10 sampled residents.
F 0609: The facility failed to timely report suspected abuse and neglect to proper authorities for some residents.
F 0610: The facility failed to conduct a thorough investigation following an allegation of verbal abuse between two residents.
Report Facts
Residents affected: 6
Residents reviewed for abuse: 10
Residents reviewed for timeliness of reporting: 9
Residents with untimely reporting: 2
Residents with unreported abuse: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Confirmed abuse incidents, reporting failures, and lack of investigation |
| S4 Food and Nutrition Manager | Food and Nutrition Manager | Witnessed Resident #3 strike Resident #4 |
| S5 Laundry Supervisor | Laundry Supervisor | Witnessed aggressive behavior between Resident #5 and Resident #6 |
| S3 Treatment Nurse | Treatment Nurse | Witnessed Resident #2 slap Resident #9 |
| S8 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed Resident #1 verbally threatened Resident #10 |
Inspection Report — Jan 4, 2024
Complaint Investigation CMS
Date: Jan 4, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify a resident's physician of a significant change in condition, failure to administer medications per physician's orders, and failure to maintain accurate medical records and nursing notes.
Complaint Details
The investigation was complaint-driven, focusing on failure to notify physicians of condition changes, medication administration errors, and inaccurate medical records. The deficiencies were substantiated based on record reviews and staff interviews.
Findings
The facility failed to notify Resident #1's physician of significant changes in condition related to gastrointestinal symptoms. The facility also failed to administer medications as ordered for Residents #2 and #3, including incomplete antibiotic courses and missed doses of blood pressure medication. Additionally, the facility failed to maintain accurate orders and nursing notes for Resident #3.
Deficiencies (3)
F 0580: The facility failed to promptly notify Resident #1's physician of significant changes in condition including multiple diarrhea stools and nausea.
F 0684: The facility failed to administer medications per physician's orders for Residents #2 and #3, including incomplete antibiotic courses and missed administration of Clonidine for elevated blood pressure.
F 0842: The facility failed to maintain accurate orders and nursing notes for Resident #3, including late entries and unclear documentation of enteral feeding orders.
Report Facts
Medication doses missed: 3
Blood pressure readings: 4
Medication administration days: 11
Medication administration days: 14
Medication doses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 Registered Nurse | Registered Nurse | Confirmed medication administration errors and late nursing notes for Resident #3. |
| S6 Nurse Practitioner | Nurse Practitioner | Ordered medications and confirmed nurses should have administered medications as ordered for Residents #2 and #3. |
| S9 Licensed Practical Nurse | Licensed Practical Nurse | Notified Nurse Practitioner of Resident #2's elevated blood pressure and medication orders. |
| S5 Licensed Practical Nurse | Licensed Practical Nurse | Acknowledged medication administration errors for Residents #2 and #3. |
| S10 Licensed Practical Nurse | Licensed Practical Nurse | Reported on medication administration and nursing notes for Residents #1 and #3. |
| S1 Administrator | Administrator | Acknowledged medication administration failures and nurse responsibilities. |
| S2 Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged medication administration failures for Resident #2. |
Inspection Report — Nov 2, 2023
Complaint Investigation CMS
Date: Nov 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation into multiple allegations including resident rights violations, abuse, medication administration, dialysis care, infection control, and safety concerns at Twin Oaks Nursing Home.
Complaint Details
The complaint investigation included issues related to resident rights, abuse, medication errors, dialysis care, infection control, and safety hazards. Multiple interviews, observations, and record reviews were conducted to assess the validity of the complaints.
Findings
The facility was found deficient in several areas including restricting a resident's access to air conditioner controls, failure to allow timely access to personal funds, inadequate supervision to prevent resident abuse and falls, inaccurate dialysis orders and poor communication with dialysis providers, improper medication administration, failure to monitor side effects of anticoagulants, and lapses in infection control hand hygiene practices.
Deficiencies (12)
F 0558: The facility failed to ensure Resident #13 had access to the air conditioner thermostat controls in her room, which was locked with a padlock against her preference.
F 0567: The facility failed to allow Resident #29 timely access to her personal funds, restricting access to specific banking hours without alternative arrangements.
F 0600: The facility failed to provide necessary supervision to prevent Resident #19 from verbally and physically abusing another resident.
F 0609: The facility failed to report an allegation of physical and verbal abuse involving Resident #19 to the state survey agency within 2 hours as required.
F 0610: The facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse involving Resident #19.
F 0678: The facility failed to ensure Resident #44's code status was accurately documented and maintained in the clinical record.
F 0684: The facility failed to implement Resident #11's insulin administration per physician's sliding scale orders.
F 0689: The facility failed to provide increased supervision to Resident #59 to prevent falls and allowed Resident #25 to possess smoking materials despite a history of unsafe smoking.
F 0698: The facility failed to ensure Resident #13's dialysis physician order was accurate and failed to maintain ongoing communication with the dialysis facility regarding Resident #13's condition.
F 0755: The facility failed to ensure only licensed personnel administered medicated creams, allowing a CNA to apply medicated Miconazole Nitrate 2% ointment to Resident #43.
F 0757: The facility failed to monitor side effects of anticoagulant medication for Resident #53.
F 0880: The facility failed to ensure proper hand hygiene by nursing staff during insulin administration and by a CNA while passing ice to residents.
Report Facts
Residents observed for glucose monitoring and insulin administration: 3
Residents observed for hand hygiene while passing ice: 7
Resident falls documented: 7
Resident #11 capillary blood glucose readings and insulin doses: 17
Resident #25 cigarettes observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed padlock on Resident #13's air conditioner and dialysis communication issues |
| S1 Administrator | Administrator | Unaware of padlock on Resident #13's air conditioner and lack of SIMS report for abuse incident |
| S5 Treatment Nurse | Treatment Nurse | Observed failing to perform hand hygiene during insulin administration |
| S17 CNA | Certified Nursing Assistant | Observed failing to perform hand hygiene while passing ice |
| S9 Certified Nursing Assistant | Certified Nursing Assistant | Applied medicated cream to Resident #43 |
| S4 MDS Coordinator | MDS Coordinator | Noted lack of side effect monitoring for Resident #53's anticoagulant medication |
Inspection Report — Aug 24, 2023
Routine CMS
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to evaluate compliance with pharmaceutical services, medication management, and drug storage regulations at Twin Oaks Nursing Home.
Findings
The facility failed to maintain accurate reconciliation records for controlled medications on medication carts and for several residents. Medication administration records were incomplete or inaccurate for multiple residents. Additionally, medications were left unattended on a medication cart and medication carts were found unlocked when unattended.
Deficiencies (2)
F0755: The facility failed to maintain accurate reconciliation records of controlled medications for 2 of 3 medication carts and for 5 residents receiving controlled medications. Medication administration records were not accurately documented for 3 of 5 sampled residents.
F0761: The facility failed to ensure medications were not left unattended on top of one medication cart and that medication carts were locked when unattended for one of three medication carts observed.
Report Facts
Residents affected: 5
Medication carts observed: 3
Missing signatures: Multiple missing nurse signatures on controlled medication schedule drug count logs for August 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 | Director of Nursing | Confirmed medication reconciliation and documentation deficiencies and acknowledged medication cart security issues |
| S3 | Registered Nurse | Acknowledged failure to sign out medications at time of administration and leaving medication cart unlocked |
| S6 | Licensed Practical Nurse | Confirmed missing signatures on schedule drug count logs |
| S8 | Licensed Practical Nurse | Acknowledged leaving medications unattended on medication cart |
Inspection Report — May 18, 2023
Complaint Investigation CMS
Date: May 18, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse and neglect, and failure to provide personal care to a resident as per their plan of care.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to timely report suspected abuse and failure to provide personal care to Resident #1.
Findings
The facility failed to ensure a CNA immediately reported an injury of unknown origin on Resident #1 and failed to provide personal hygiene care to Resident #1 during a shift on 04/22/2023, as confirmed by observation, interviews, and record review.
Deficiencies (2)
F 0609: The facility failed to ensure a CNA immediately reported an injury of unknown origin when a bruise was observed on Resident #1's forehead. The bruise was not reported timely despite multiple observations and interviews confirming the delay.
F 0677: The facility failed to provide personal care and assistance with activities of daily living to Resident #1 as required by the plan of care. Camera footage showed Resident #1 did not receive personal hygiene care during a shift on 04/22/2023.
Report Facts
Residents sampled: 5
Date of injury observation: Apr 22, 2023
Time personal care not provided: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 CNA | Certified Nursing Assistant | Failed to report the bruise on Resident #1's forehead immediately. |
| S6 CNA | Certified Nurse Assistant | Acknowledged not performing personal hygiene care to Resident #1 during shift on 04/22/2023. |
| S4 Registered Nurse | Registered Nurse | Reported being informed of the bruise on Resident #1's forehead at approximately 1:00 a.m. on 04/22/2023. |
| S1 Administrator | Administrator | Acknowledged the CNA should have reported the bruise immediately and conducted investigation. |
| S2 Weekend Supervisor | Weekend Supervisor | Observed the bruise on Resident #1's forehead on 04/23/2023. |
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