Evangeline Oaks: CPR Delay During Emergency - LA
The incident unfolded on the morning of June 2, 2025, at Evangeline Oaks Guest House when certified nursing assistant S6CNA went to collect breakfast trays from Resident 5's room.
S6CNA found the resident in bed with open eyes but completely unresponsive. She immediately called weekend charge nurse S7WC and licensed practical nurse S3LPN to the room.
When S3LPN arrived, she observed Resident 5 "kind of slouched in her bed" and attempted to arouse the resident without success. Despite being CPR-certified, S3LPN admitted to federal inspectors that she "did not start chest compressions immediately."
Instead, at 7:52 a.m., S3LPN sent a text message to Director of Nursing S1DON, who was not yet at the facility. The message reported that Resident 5 was unresponsive with labored breathing and non-reactive pupils.
S1DON immediately instructed S3LPN by text to call 911 and start CPR chest compressions.
But the certified staff still did not begin lifesaving measures.
Weekend charge nurse S7WC called 911 while the resident remained without chest compressions. S7WC later told investigators she observed Resident 5 "sitting up, kind of slouched in bed, not responding and her eyes were closed."
The delay continued until S1DON arrived at the facility around 8:00 a.m. She went directly to Resident 5's room and performed a sternal rub with no response from the resident. Only then did chest compressions finally begin.
"S1DON then hollered for S7WC to call 911 and then S1DON started chest compressions," according to the inspection report.
The timeline shows at least an eight-minute gap between discovering the unresponsive resident and beginning CPR. S3LPN texted the director at 7:52 a.m., but compressions did not start until S1DON arrived around 8:00 a.m.
During interviews with federal inspectors in August, S1DON confirmed that both S6CNA and S3LPN held current CPR certifications and "should have started CPR immediately after discovering Resident 5 was unresponsive."
The accounts from staff members revealed confusion about who should take action during the emergency. S6CNA described finding the resident with "eyes open but Resident 5 was not responding" and calling other staff rather than beginning resuscitation efforts herself.
S3LPN acknowledged the resident's critical condition, telling inspectors that Resident 5 "was breathing weird and was not acting like herself" when S6CNA summoned her to the room.
Yet despite recognizing the emergency and holding CPR certification, S3LPN waited for the director's arrival rather than starting chest compressions as her training required.
S7WC provided a slightly different account, describing the resident as having "eyes closed" rather than open, but confirmed the same sequence of events and delays.
The federal inspection, conducted as a complaint investigation, found the facility violated regulations requiring immediate emergency care. Inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting few residents.
But the case illustrates a breakdown in basic emergency response protocols. Three staff members encountered an unresponsive resident showing signs of cardiac arrest, yet none began the chest compressions that could have maintained blood circulation to vital organs.
The director of nursing's immediate text instruction to "call 911 and start CPR" shows that proper protocol was clear. The facility's own leadership recognized that certified staff should have begun lifesaving measures without delay or supervision.
Medical research consistently shows that brain damage from lack of oxygen begins within four to six minutes during cardiac arrest. Every minute without chest compressions reduces survival chances by 7 to 10 percent.
At Evangeline Oaks, those critical minutes ticked away while certified nursing staff waited for their supervisor to drive to work and take action they were trained and authorized to perform themselves.
The inspection report does not indicate the outcome for Resident 5 or whether the delayed response contributed to any lasting harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evangeline Oaks Guest House from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
Evangeline Oaks Guest House in Carencro, LA was cited for violations during a health inspection on August 27, 2025.
S6CNA found the resident in bed with open eyes but completely unresponsive.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.