Oak Lane Wellness & Rehabilitative Center

In the surveyor’s words

From the most serious findings on record at Oak Lane Wellness & Rehabilitative Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 2, 2025

  Based 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. […]

• Actual harm, isolatedF881May 22, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF576Jul 15, 2026

  Based 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. Findings:On 07/14/2026 at 9:30 a.m., a resident council meeting was conducted with Residents #7, #15, #21, #28 and #63 who each confirmed they did not receive any mail on Saturdays. On 07/14/2026 at 9:40 a.m., an interview with S7HR confirmed the residents get their mail on weekdays Monday through Friday. She stated the mail was delivered to the facility on Saturday, however, the residents received the mail on Monday morning after the facility's office staff sorted through the mail. […]

• No harm, potential for more than minimal, widespreadF812Jul 15, 2026

  Based 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.Findings:On 07/13/2026, a review of the facility's policy titled, Food Receiving and Storage, with a review date of 05/25/2026, revealed, in part; 8. […]

• No harm, potential for more than minimal, patternF656Mar 25, 2026

  Based 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.Findings:Review of Resident #2's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease and dementia.Review of Resident #2's November 2025 physician's order and TAR (Treatment Administration Order) revealed the following order dated 11/07/2025: Skin tear to R (right) forearm. […]