Oak Lane Wellness & Rehabilitative Center

Inspectors wroteBased on interviews, the facility failed to ensure the residents rights to receive their mail on Saturday. This deficient practice has the potential to affect the census of 74 residents that reside in the facility.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure that cut produce stored in the refrigerator was protected from contamination and that refrigerated produce was labeled and dated. A total of 74 residents consumed meals from the kitchen.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents and/or residents' RP (Responsible Party) were informed of the risks, benefits, and side effects of psychotropic/antipsychotic medications for 1 (Resident #3) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement physician orders to address weight loss by failing to offer a dietary supplement that was ordered for 1 (Resident #8) out of 2 residents investigated for nutrition.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure residents received the appropriate amount of oxygen as ordered by the physician for 1 (#2) of 3 residents review for respiratory care

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. This was evidenced by staff failing to perform hand hygiene after removing gloves. This deficient practice had the potential to affect 74 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's plan of care was implemented as ordered through five consecutive months by failing to follow physician orders for completing wound care and monitor swelling for 1 (Resident #2) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to develop and/or implement a comprehensive person-centered plan of care and/or physician's orders for 1 (Resident #38) out of 29 sampled residents. This deficient practice was evidenced when the facility failed to implement standing orders for constipation for Resident #38.

Inspectors wroteBased on observations and interviews, the facility failed to maintain professional standards for food service safety by failing to: 1. Discard food items that were past the used by date, 2. Label and date opened food items stored in the walk in cooler, 3. Label and date an opened food item in the area where food is prepared 4. Label and date an opened food item in the pantry, 5. Remove a dented can from the dry storage area, 6. Ensure kitchen staff wear proper hair restraints. The facility's census was 69.

Inspectors wroteBased on observation and interviews, the facility failed to promote and facilitate residents' self- determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 1 (#59) out of 29 sampled residents. The facility failed to provide a diet according to Resident #59's food preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #66) out of 29 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) receives services to maintain personal hygiene for 1 (#16) of 1 (#16) residents investigated for ADL care. The sample size was 29.

Inspectors wroteBased on observations and interviews the facility failed to properly store respiratory equipment for 2 (Resident #16 and Resident #22) out of 3 residents (Resident #16, Resident #22 and Resident # 63) investigated for respiratory care.

Inspectors wroteResident #50 Review of Resident #50's electronic medical record revealed he was admitted to the facility on 09/12//2022 with the following diagnoses in part, but not limited to, Type 2 Diabetes mellitus, cerebral infarction and chronic obstructive pulmonary disease. On 06/23/2025 at 10:20 a.m., a medication administration observation was conducted with S15LPN (Licensed Practical Nurse). After S15LPN drew up Resident #50's insulin injection, she proceeded to the resident's room and administered his injection without donning gloves prior to giving the injection. On 06/23/2025 at 10:30 a.m., an interview was conducted with S15LPN. S15LPN confirmed she did not wear gloves when she administered Resident #50's injection. She stated that she should have worn gloves to give the injection. [...]

Inspectors wroteBased on record reviews, observations, and interviews, the facility staff failed to recognize and properly respond to a resident who was demonstrating exit seeking behaviors or recognize the Wanderguard alarm to prevent elopement for 1 (Resident #1) of 5 residents investigated for elopement (Resident #1, #4, #5, #6 and #7). This deficient practice resulted in an Immediate Jeopardy on 03/22/2025 at 10:40 a.m. when Resident #1, a moderately cognitively impaired resident, eloped from the facility located in a residential area. On the morning of 03/22/2025, prior to his elopement, Resident #1 asked staff members for the code to the facility's door alarm and expressed that he wanted to go home before exiting the facility undetected by staff. Staff failed to recognize the residents exit seeking behavior and the sound of the wanderguard as he went out of the door. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 resident (#2) out of 7 (#1,#2, #3, #4, #5, #6, #7) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to implement its antibiotic stewardship policy to timely evaluate culture and sensitivity results in order to determine appropriate antibiotic usage by failing to: 1. Obtain culture report and sensitivity data in a timely manner in order to initiate possible treatment for Residents #43 and #77 and; 2. Notify the physician of culture report and sensitivity data in order to ensure Resident #380 was prescribed the appropriate antibiotic, out of 6 (Residents #34, #43, #54, #65, #70, #77, and #380) residents reviewed for infection control tracking and trending during the Infection Control facility task. The facility's census was 77. [...]

Inspectors wroteBased on in record review and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility by failing to ensure dialysis communication forms were filled out completely for 1 (#66) resident sampled for dialysis. The deficient practice had the potential to affect 1 dialysis resident that resided in the facility.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure recipes for pureed, chopped, and bite sized meals were used during meal preparation. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for 1 (#26) resident who received pureed meals, 6 residents ( #16, #19, #29, #32, #49 and #65) who received mechanical chopped meals, and 13 residents (#2, #4, #5, #7, #23, #28, #30, #42, #46, #58, #68, #69, and #71) who received bite sized meals.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment for 1 (#50) out of 3 (#44, #48, and #50) residents investigated for environment out of a total sample of 55 residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to complete a comprehensive assessment, including resident's dental status, within 14 days of admission for 1 (#131) of 1 (#131) resident reviewed for pain management from a sample of 55 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were opened, completed, and electronically transmitted in a timely manner for 1 (#74) out of 3 (#51, #66 and #74) residents investigated for Resident Assessment out of a finalized sample of 55 residents. This deficient practice had the potential to affect 77 residents that resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASRR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#20) out of 2 (#3,#20) sampled residents investigated for PASRR. This had a potential to effect a census of 77.

Inspectors wroteBased on staff interviews, observations and record review, the facility failed to follow the physician's orders for 1 (#8) resident as evidence by failing to check for residual before the nurse administered PEG (percutaneous endoscopic gastrostomy) tube water flush and bolus feeding as scheduled. The final sample size was 55.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to effectively manage pain for 1 (#131) of 1 (#131) resident reviewed for pain management out of sample of 55 residents.

Inspectors wroteBased on observations, interview and policy and procedure review, the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing to ensure opened containers in dry storage and foods stored in the facility's freezer were labeled and dated.

Inspectors wroteBased on record review and interviews, the facility failed to notify the responsible party for 1 (#1) of 3 (#1, #2, #3) residents sampled for an incident that involved suspected sexual abuse.

Inspectors wroteBased on record review, video review, and interview, the facility failed immediately implement safeguards to protect a resident without the capacity to consent to sexual activity from sexual abuse for 1 (#1) of 3 (#1, #2, #3) sampled residents when Resident #2 had non-consensual sexual contact with Resident #1. This deficient practice had the potential to affect 3 female residents who resided on the dementia care unit.

Inspectors wroteBased on record review and interviews, the facility failed to ensure alleged violation of sexual abuse were reported immediately, but not later than 24 hours after the allegation was made to the State Survey Agency for 1 (#1) out of 3 (#1, #2, #3) sampled residents. This had the potential to effect a census of 78 residents.