Inspection Reports for
Lady of the Oaks Retirement Manor
1005 ERASTE LANDRY ROAD, LAFAYETTE, LA, 70506
Back to Facility Profile7 Reports
Inspection Report — Jun 3, 2025
Routine CMS
Date: Jun 3, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, food storage, environment safety, and assistance with activities of daily living at Lady of the Oaks Retirement Manor.
Findings
The facility failed to ensure residents' care plans and physician orders were followed for therapeutic diets, oxygen administration, and assistance with activities of daily living. Additionally, food storage practices were inadequate with unlabeled and expired food items, and the environment was unsafe due to exposed wiring near a resident's bed.
Deficiencies (6)
Failed to administer therapeutic diets as prescribed for residents #11 and #102.
Failed to maintain right and left ear cushions to nasal cannula for Resident #91.
Failed to assist Resident #102 with meal setup and oxygen administration as ordered.
Failed to provide assistance with incontinent care for Residents #61 and #72.
Failed to store food properly: opened food items not labeled and expired food present in walk-in cooler and freezer.
Failed to provide a safe, homelike environment due to exposed black wire hanging near Resident #100's bed.
Report Facts
Residents sampled for ADL care: 8
Residents affected by ADL care deficiency: 2
Residents sampled for environment: 6
Residents affected by environment deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5LPN | Licensed Practical Nurse | Interviewed regarding diet and oxygen administration deficiencies for Residents #11, #102, and #72 |
| S6DM | Dietary Manager | Interviewed regarding diet and fluid administration for Residents #11 and #102 |
| S8CNA | Certified Nursing Assistant | Interviewed regarding missed meal tray setup for Resident #102 |
| S7LPN | Licensed Practical Nurse | Confirmed diet orders for Resident #102 |
| S10LPN | Licensed Practical Nurse | Confirmed nasal cannula ear cushion orders for Resident #91 |
| S4CNA | Certified Nursing Assistant | Interviewed regarding incontinent care and environmental safety concerns |
| S2ADON | Assistant Director of Nursing | Interviewed regarding CNA responsibilities for resident care |
| S1DS | Dietary Supervisor | Interviewed regarding food storage deficiencies |
| S12LPN | Licensed Practical Nurse | Observed and interviewed regarding oxygen administration for Resident #102 |
| S11CNA | Certified Nursing Assistant | Checked oxygen saturation level for Resident #102 |
| S13MS | Maintenance Supervisor | Interviewed regarding environmental safety and maintenance issues |
Inspection Report — Feb 18, 2025
Complaint Investigation CMS
Date: Feb 18, 2025
Visit Reason
The inspection was conducted following a complaint regarding neglect, specifically failure to provide incontinence care to a dependent resident (Resident #3) on 01/23/2025.
Complaint Details
The complaint was substantiated. Resident #3's grievance indicated she was left wet for over four hours without assistance. Video evidence and staff interviews confirmed the CNA did not perform required rounds or assist the resident as needed.
Findings
The facility failed to protect Resident #3 from neglect by not providing timely incontinence care. The CNA assigned did not complete required two-hour rounds, left the resident wet, turned off the call light, and did not return to assist despite availability of other staff. Interviews and video evidence confirmed these findings.
Deficiencies (1)
Failure to provide incontinence care for a dependent resident, resulting in neglect.
Report Facts
Residents sampled: 3
Residents affected: 1
Time CNA failed to make rounds: 4
CNA shift time: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 CNA | Certified Nursing Assistant | CNA assigned to Resident #3 who failed to provide timely incontinence care |
| S2 ADON | Assistant Director of Nursing | Completed grievance form and investigated complaint |
| S1 DON | Director of Nursing | Interviewed regarding CNA rounding requirements and findings |
| S4 CNA | Certified Nursing Assistant | Floater CNA available to assist on 01/23/2025 |
| S5 LPN | Licensed Practical Nurse | Resident #3's nurse on 01/23/2025 who overheard CNA not asking for assistance |
Inspection Report — Apr 11, 2024
Annual Inspection CMS
Date: Apr 11, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey of Lady of the Oaks Retirement Manor to assess compliance with regulatory requirements and evaluate resident care and facility operations.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments, incomplete and improperly implemented care plans, failure to maintain proper feeding tube care, administration of medication despite documented allergies, lack of required RN staffing, failure to coordinate hospice care documentation, and inadequate cleanliness of medication carts.
Deficiencies (7)
Failure to ensure accurate completion of Minimum Data Set (MDS) assessments, specifically coding bed alarm use incorrectly for Resident #77.
Failure to develop and implement complete care plans meeting residents' needs, including repositioning Resident #47 every 2 hours, care plan for hand roll use for Resident #72, and ensuring Resident #77's bed alarm was functioning properly.
Failure to ensure proper care and timely changing of enteral feeding bags for Resident #61.
Failure to ensure nursing staff competency, resulting in administration of morphine to Resident #3 despite documented allergy.
Failure to ensure a Registered Nurse was on duty for 8 consecutive hours on 10/21/2023 and 10/22/2023.
Failure to coordinate hospice care documentation for Resident #152, including absence of hospice election form, plan of care, and physician certification.
Failure to maintain cleanliness of medication cart drawers, with sticky residue and medication bottles stuck to drawer surfaces.
Report Facts
Sampled residents: 33
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dates without RN coverage: 2
Medication bottles: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1DON | Director of Nursing | Confirmed bed alarm issues, lack of RN staffing, and medication cart cleanliness problems |
| S8MDS | Minimum Data Set Lead Coordinator | Confirmed inaccurate MDS coding for Resident #77 |
| S5CNA | Certified Nursing Assistant | Verified bed alarm was not functioning for Resident #77 |
| S4MDS | Minimum Data Set Nurse | Confirmed care plan deficiencies for Resident #72 |
| S3LPN | Licensed Practical Nurse | Confirmed feeding tube bag was not changed timely for Resident #61 |
| S12LPN | Licensed Practical Nurse | Administered morphine to Resident #3 despite allergy; explained medication administration practices |
| S9MDS | Minimum Data Set Nurse | Confirmed morphine allergy and medication administration issues for Resident #3 |
| S2DON | Director of Nursing | Confirmed morphine allergy administration and lack of RN staffing on specified dates |
| S2ADON | Assistant Director of Nursing | Confirmed missing hospice documentation for Resident #152 |
| S7LPN | Licensed Practical Nurse | Observed unclean medication cart drawers |
Inspection Report — Sep 26, 2023
Routine CMS
Date: Sep 26, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding compliance with COVID-19 droplet isolation precautions.
Findings
The facility failed to maintain an effective infection prevention and control program as staff did not wear the required Personal Protective Equipment (PPE) when entering isolation rooms, potentially exposing 100 residents to COVID-19.
Deficiencies (1)
Failure to implement an infection prevention and control program, evidenced by staff not wearing required PPE before entering isolation rooms.
Report Facts
Residents affected: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (S2CNA) | Observed not wearing full PPE when entering isolation rooms | |
| Infection Preventionist (S1IP) | Interviewed and confirmed PPE requirements for isolation rooms |
Inspection Report — Jul 26, 2023
Complaint Investigation CMS
Date: Jul 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to follow a resident's care plan and physician's orders, specifically concerning communication tools, blood sugar checks, and medication administration for Resident #5.
Complaint Details
The complaint investigation focused on Resident #5, substantiated by findings that staff failed to follow care plans and physician orders, including communication aids, blood sugar monitoring, and medication administration. The resident experienced hypoglycemia and was hospitalized after being found unresponsive.
Findings
The facility failed to ensure Resident #5's care plan and physician's orders were followed, including failure to use a communication board and provide eyeglasses, failure to perform accuchecks upon readmission, and failure to administer prescribed medication Pyridium. These failures resulted in minimal harm or potential for actual harm to a few residents.
Deficiencies (4)
Facility staff failed to use a communication board and ensure Resident #5's eyeglasses were available per the resident's care plan.
S6LPN failed to implement an order for accuchecks (blood sugar checks) upon readmission to the facility.
S7LPN failed to implement a medication, Pyridium, as ordered on 06/15/2023.
S6LPN failed to obtain a capillary blood glucose (CBG) per the facility's policy when Resident #5 had a change in condition.
Report Facts
Residents sampled: 5
Residents affected: 1
Medication dosage: 100
Medication frequency: 3
Date of medication order: Jun 15, 2023
Date of resident admission: Jan 30, 2023
Date of survey completion: Jul 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6LPN | Licensed Practical Nurse | Failed to implement accuchecks and failed to obtain CBG during resident's change in condition |
| S7LPN | Licensed Practical Nurse | Failed to enter order and administer Pyridium medication |
| S1DON | Director of Nursing | Confirmed failures in communication tool use and medication order entry |
| S2ADON | Assistant Director Nursing | Confirmed communication tool was not being used as ordered |
| S3NP | Nurse Practitioner | Provided verbal orders for accuchecks and confirmed medication orders |
Inspection Report — Jun 13, 2023
Complaint Investigation CMS
Date: Jun 13, 2023
Visit Reason
The inspection was conducted to investigate allegations of physical abuse between residents in the facility, specifically resident-to-resident altercations reported on 02/21/2023 and 04/10/2023.
Complaint Details
The complaint investigation involved allegations of physical abuse between residents. The incidents occurred on 02/21/2023 and 04/10/2023, with no injuries reported. The facility's investigation confirmed the altercations and failure to protect residents from abuse.
Findings
The facility failed to protect residents from physical abuse by other residents in two separate incidents involving Resident #2 and Resident #6 on 04/10/2023, and Resident #3 and Resident #7 on 02/21/2023. Both incidents involved physical altercations with no injuries reported but demonstrated failure in preventing resident-to-resident abuse.
Deficiencies (2)
Failed to protect Resident #2 from being hit on the arm by Resident #6 on 04/10/2023.
Failed to protect Resident #3 from being hit on the leg by Resident #7 on 02/21/2023.
Report Facts
Residents reviewed for resident-to-resident altercations: 6
Residents affected: 2
BIMS score: 15
BIMS score: 3
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6 LPN | Licensed Practical Nurse | Nurse on duty during 02/21/2023 incident who reported the altercation |
| S4 LPN | Licensed Practical Nurse | Confirmed knowledge of the 02/21/2023 altercation |
| S1 ADM | Administrator | Reported the incidents and confirmed occurrence of altercations |
| S5 LPN | Licensed Practical Nurse | Witnessed and reported the 04/10/2023 incident |
| S2 DON | Director of Nursing | Confirmed awareness of the 04/10/2023 incident |
Inspection Report — Mar 29, 2023
Annual Inspection CMS
Date: Mar 29, 2023
Visit Reason
The inspection was conducted as part of a regulatory compliance survey to assess the facility's adherence to healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to update PASRR screenings, failure to follow physician orders related to PEG tube care and pressure ulcer prevention, improper storage of controlled drugs, failure to serve prescribed therapeutic diets, and unsafe kitchen equipment maintenance.
Deficiencies (6)
Failed to ensure a resident's MDS assessment was accurately coded to reflect functional impairment in range of motion.
Failed to ensure residents identified with a Mental Disorder and/or Intellectual Disability had an accurate PASRR Level 1 and/or Level 2 screening.
Failed to follow physician's orders for PEG tube water flush residual checks and failed to ensure alternating air mattress was functioning.
Failed to ensure controlled drugs awaiting disposal were separately locked as required.
Failed to serve a resident's physician prescribed therapeutic diet (no fried foods).
Failed to ensure kitchen equipment (ice machine) was maintained in safe operating condition.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 105
Residents affected: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4LPN | Licensed Practical Nurse | Named in deficiency for failing to check residual before PEG tube water flush and unplugging alternating air mattress pump |
| S1DON | Director of Nursing | Confirmed Resident #3's care needs and alternating air mattress issue |
| S2DON | Director of Nursing | Interviewed regarding controlled drug storage and policy absence |
| S5DM | Dietary Manager | Verified kitchen equipment issues and diet preparation concerns |
| S1QI | Quality Improvement/Corporate Nurse | Interviewed about controlled drug storage practices |
| S3ADON | Assistant Director of Nursing | Confirmed proper procedure for PEG tube water flush residual checks |
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