Inspection Reports for
Oak Lane Wellness & Rehabilitative Center
1400 W MAGNOLIA, EUNICE, LA, 70535
Back to Facility Profile6 Reports
Inspection Report — Jun 25, 2025
Annual Inspection CMS
Date: Jun 25, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to honor resident dietary preferences, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living, improper respiratory equipment storage, food safety violations, and lapses in infection prevention and control practices.
Deficiencies (7)
F 0561: The facility failed to promote and facilitate resident self-determination by not honoring Resident #59's dietary dislikes of mixed vegetables and beans.
F 0641: The facility failed to ensure Resident #66's discharge assessment was accurately coded as planned rather than unplanned.
F 0656: The facility failed to implement standing orders for constipation for Resident #38, who did not receive prescribed laxatives despite no bowel movements for six days.
F 0677: The facility failed to provide adequate personal hygiene care for Resident #16, who was observed with dried stool on her hand and nails.
F 0695: The facility failed to properly store respiratory equipment for Residents #16 and #22, including failure to store nebulizer mask in a bag and failure to change CPAP mask storage bags monthly.
F 0812: The facility failed to maintain food service safety by storing expired food, unlabeled opened food items, dented cans, and allowing kitchen staff to work with exposed facial hair.
F 0880: The facility failed to maintain infection prevention and control by staff not wearing gloves during insulin administration and not wearing gowns and gloves when providing care to a resident on enhanced barrier precautions.
Report Facts
Expired chocolate milk containers: 19
Opened food items without label or date: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S20LPN | Licensed Practical Nurse | Named in failure to administer standing orders for constipation for Resident #38 |
| S2DON | Director of Nursing | Confirmed failure to administer constipation medications for Resident #38 and improper respiratory equipment storage |
| S11CNA | Certified Nursing Assistant | Responsible for Resident #16's care when hygiene failure was observed |
| S15LPN | Licensed Practical Nurse | Failed to wear gloves when administering insulin to Resident #50 |
| S19CNA | Certified Nursing Assistant | Failed to wear gown while providing bed bath to Resident #31 on enhanced barrier precautions |
Inspection Report — Apr 2, 2025
Complaint Investigation CMS
Date: Apr 2, 2025
Visit Reason
The inspection was conducted due to complaints regarding pressure ulcer care and elopement risk management at Oak Lane Wellness & Rehabilitative Center.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent pressure ulcers in one resident and failed to prevent elopement of another resident, resulting in immediate jeopardy that was removed after corrective actions.
Findings
The facility failed to provide appropriate pressure ulcer care for one resident, resulting in a facility-acquired unstageable wound. Additionally, the facility failed to prevent elopement of a cognitively impaired resident due to inadequate staff response to exit-seeking behavior and alarm systems, resulting in immediate jeopardy that was later removed after corrective actions.
Deficiencies (2)
F 0686: The facility failed to ensure a resident received care to prevent pressure ulcers, as weekly body audits were not documented and a facility-acquired unstageable wound was identified.
F 0689: The facility failed to recognize and properly respond to exit-seeking behavior and Wanderguard alarms, resulting in a resident eloping from the facility and immediate jeopardy to resident health or safety.
Report Facts
Residents sampled for pressure ulcer care: 7
Residents investigated for elopement: 5
Resident elopement distance: 0.2
Resident walking distance: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5 CNA | Certified Nursing Assistant | Named in elopement incident and interview regarding failure to respond to alarm |
| S6 CNA | Certified Nursing Assistant | Named in elopement incident and interview regarding failure to respond to alarm |
| S7 TN | Treatment Nurse | Named in pressure ulcer care deficiency and interview |
| S4 ALPN | Agency Licensed Practical Nurse | Completed incident report on resident elopement |
| S1 ADM | Administrator | Interviewed regarding elopement incident and facility policies |
Inspection Report — May 22, 2024
Annual Inspection CMS
Date: May 22, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including environmental safety hazards, incomplete resident assessments, failure to follow physician orders, inadequate pain management, incomplete dialysis communication, improper food preparation and storage, and failure to timely monitor and report antibiotic use. Deficiencies ranged from minimal to actual harm.
Deficiencies (10)
F 0584: The facility failed to provide a safe, clean, and homelike environment, evidenced by paint scraped off bathroom walls and a sharp metal trim in Resident #50's room that posed a potential harm.
F 0636: The facility failed to complete a comprehensive assessment including dental status within 14 days of admission for Resident #131.
F 0640: The facility failed to ensure resident assessments were opened, completed, and electronically transmitted in a timely manner for Resident #74's discharge assessment.
F 0644: The facility failed to refer Resident #20 with a newly diagnosed mental disorder to the appropriate state authority for Level II PASRR evaluation.
F 0656: The facility failed to follow physician orders for Resident #8 by not checking gastric residual before administering PEG tube water flush and bolus feeding.
F 0697: The facility failed to effectively manage pain for Resident #131, who reported continuous severe oral pain that was inadequately treated.
F 0698: The facility failed to ensure dialysis communication forms were completely filled out for Resident #66, affecting ongoing communication with the dialysis center.
F 0805: The facility failed to ensure recipes for pureed, chopped, and bite sized meals were used during meal preparation, risking nutritional adequacy and resident satisfaction.
F 0812: The facility failed to store food in accordance with professional standards by not labeling and dating opened containers in dry storage and freezer.
F 0881: The facility failed to timely obtain and notify physicians of culture and sensitivity results for Residents #43, #77, and #380, resulting in actual harm for Resident #43 due to untreated urinary tract infection.
Report Facts
Residents in sample: 55
Dialysis communication forms incomplete: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4MS | Maintenance Supervisor | Confirmed environmental hazards in Resident #50's bathroom |
| S2DON | Director of Nursing | Confirmed environmental hazards and failure to follow physician orders |
| S11MDS | MDS Coordinator | Confirmed incomplete oral assessment for Resident #131 |
| S10LPN | Licensed Practical Nurse | Confirmed missing discharge assessment for Resident #74 |
| S7SSD | Social Service Director | Confirmed failure to submit Level II PASRR for Resident #20 |
| S5LPN | Licensed Practical Nurse | Observed not checking gastric residual before feeding Resident #8 |
| S3ADON | Assistant Director of Nursing | Confirmed incomplete dialysis communication forms and pain management issues |
| S8DM | Dietary Manager | Confirmed failure to follow recipes and improper food storage |
| S9KS | Kitchen Staff | Observed preparing meals without following recipes |
| S11LPN | Licensed Practical Nurse | Documented Resident #43's symptoms and transfer to emergency room |
Inspection Report — May 14, 2024
Complaint Investigation CMS
Date: May 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of suspected sexual abuse involving residents at the facility.
Complaint Details
The complaint investigation involved an incident on 04/27/2024 where Resident #2 attempted to remove Resident #1's pants. Resident #1 had severe cognitive impairment and lacked capacity to consent. The facility delayed notifying Resident #1's responsible party until 04/29/2024 and failed to report the incident to the State Survey Agency within 24 hours. The facility also failed to implement adequate safeguards to protect residents from Resident #2's inappropriate sexual behaviors.
Findings
The facility failed to notify the responsible party immediately about the incident involving suspected sexual abuse of Resident #1 by Resident #2. The facility also failed to implement safeguards to protect vulnerable residents from sexual abuse and failed to timely report the incident to appropriate authorities within 24 hours.
Deficiencies (3)
F 0580: The facility failed to notify the responsible party for Resident #1 of an incident involving suspected sexual abuse on 04/27/2024 in a timely manner.
F 0600: The facility failed to implement safeguards to protect Resident #1 from non-consensual sexual contact by Resident #2, who exhibited inappropriate sexual behaviors.
F 0609: The facility failed to report suspected sexual abuse to the State Survey Agency within 24 hours as required by policy and regulations.
Report Facts
Incident date: Apr 27, 2024
Notification date: Apr 29, 2024
Resident #1 BIMS score: 2
Resident #2 BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Involved in the incident response and failed to notify responsible party immediately |
| S2DON | Director of Nursing | Confirmed delayed notification and late reporting of the incident |
| S1ADM | Administrator | Responsible for oversight and was not notified immediately of the incident |
| S5LPN | Licensed Practical Nurse | Monitored residents but did not implement specific interventions for Resident #2's behaviors |
| S6LPN | Licensed Practical Nurse | Aware of Resident #2's inappropriate behaviors but did not monitor or document them |
Inspection Report — Aug 22, 2023
Complaint Investigation CMS
Date: Aug 22, 2023
Visit Reason
The inspection was conducted to investigate compliance with infection prevention and control policies, specifically related to staff adherence to transmission-based precautions and hand hygiene for residents on contact precautions.
Complaint Details
The investigation was complaint-related, focusing on staff noncompliance with PPE and hand hygiene protocols for Resident #4, who was on contact precautions due to ESBL infection. The complaint was substantiated by observations and interviews confirming staff did not follow required precautions.
Findings
The facility failed to ensure staff wore appropriate personal protective equipment (PPE) and performed hand hygiene when providing care to a resident on contact transmission-based precautions. This deficient practice affected one resident and had the potential to affect others on the same hall.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Staff did not wear gowns or perform hand hygiene as required when caring for a resident on contact precautions with a multi-drug resistant organism.
Report Facts
Residents on transmission-based precautions: 4
Residents in sample: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5ACNA | Agency Certified Nursing Assistant | Named in findings for failure to wear gown and perform hand hygiene when caring for Resident #4 |
| S6ACNA | Agency Certified Nursing Assistant | Named in findings for failure to wear gown and perform hand hygiene when caring for Resident #4 |
| S4ALPN | Agency Licensed Practical Nurse | Interviewed regarding Resident #4's contact precautions and antibiotic treatment |
| S2ADONIP | Assistant Director of Nursing, Infection Preventionist | Interviewed and confirmed staff noncompliance with infection control policies |
| S1DON | Director of Nursing | Interviewed and confirmed staff noncompliance with infection control policies |
Inspection Report — May 24, 2023
Routine CMS
Date: May 24, 2023
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident assessments, care planning, respiratory care, advance directives, and food service sanitation.
Findings
The facility failed to accurately code a resident's PASARR Level II on the MDS, failed to include Level II PASARR in care plans and invite residents or responsible parties to care plan meetings, had conflicting DNR and full code orders in resident records, failed to clean CPAP machine reservoirs properly, and had unsanitary air conditioning vents in the kitchen area.
Deficiencies (5)
F0641: The facility failed to ensure a resident's PASARR Level II was accurately coded on the MDS for the comprehensive assessment for 1 resident. The facility census was 76 residents.
F0657: The facility failed to develop a complete care plan within 7 days of the comprehensive assessment and failed to invite 1 resident or responsible party to care plan meetings for 2 residents reviewed. The facility census was 76 residents.
F0678: The facility failed to ensure a resident's medical record clearly reflected the resident's wishes for do not resuscitate for 1 of 2 residents reviewed for hospice care. Conflicting DNR and full code orders were found in the resident's records. The facility census was 76 residents.
F0695: The facility failed to clean a resident's CPAP machine reservoir as required by policy for 1 of 4 residents reviewed for respiratory care. Observations confirmed a slimy film on the reservoir. The facility census was 76 residents.
F0812: The facility failed to ensure the air conditioning ventilation system above the food preparation and serving area was sanitary, with vents covered in brown greasy lint, potentially affecting 76 residents.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4MDS | Minimum Data Set Nurse | Interviewed regarding PASARR coding and care plan meeting invitations |
| S3ADON | Assistant Director of Nursing | Confirmed care plan meeting invitation procedures |
| S6LPN | Licensed Practical Nurse | Reviewed Resident #60's electronic record and orders |
| S7RNS | Registered Nurse Supervisor | Interviewed about DNR order verification practices |
| S2DON | Director of Nursing | Reported on procedures for verifying resident code status |
| S4ADON | Assistant Director of Nursing | Observed CPAP machine reservoir condition |
| S8Cook | Cook | Observed unsanitary air conditioning vents in kitchen |
| S9DM | Dietary Manager | Confirmed unsanitary condition of air conditioning vents |
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