Oakbridge Terrace at Normandy Farms Estates.

“A resident who fell and was hospitalized was not reported to the Department within the required 24 hours. The facility failed to timely submit the Reportable Incident Report to DHS.”

“A resident with severe vascular dementia in the secured dementia unit was found lying face down on the patio with dried blood and facial injuries on 08/12/2025. The resident had been found on the patio again on 08/16/2025 despite being on hourly checks following the previous fall. Staff did not provide adequate supervision and continued resetting alarm systems without monitoring the resident's safety.”

“Resident #2's OTC medications, including two bottles of fluticasone nasal spray (50 mcg), Visine eye drops, and Kirkland Allergy nasal spray, were unlocked, unattended, and accessible in the resident's room.”

“Resident #1's record did not include a current list of medications for self-administration. Three medications were found that were not on the current list: Acetaminophen 500 mg, Metoprolol Succ ER 100 mg, and ofloxacin 0.3%.”

“There was no thermometer in the refrigerator in the Cranberry Wing kitchenette. Food requiring refrigeration must be stored at or below 40°F and thermometers are required in refrigerators and freezers.”

“An 18-ounce aerosol can of Monogram Stainless Steel Cleaner and a 17-ounce container of Ecolab Stainless Steel Cleaner, both labeled flammable material, were found unlocked, unattended, and accessible to residents in the memory care unit.”

“Metoprolol Succ ER 100 mg prescribed for resident #1 was kept in the residence although the medication was discontinued on 04/25/2025. Only current medications may be kept in the residence.”

“Resident #2's Fluticasone Propionate Nasal Spray had expired on 09/24 and another bottle had an expiration date of 11/24. Expired medications must be destroyed in a safe manner.”

“Resident #3 was prescribed Lisinopril 30mg daily but was administered Lisinopril 20mg on 07/16/25 and 07/17/25. Resident #4 was prescribed Admelog Solostar 100/ml units with specific glucose level requirements but was administered 5 units on 07/15/25 at 7:30am and 11:30am when blood sugars were 97 and 94 respectively, not meeting the prescribed criteria.”

“Resident #1 had two blister packs with medication slots that were punctured and medication taped inside, creating a sanitary concern with compromised foil integrity of bubble packed medications.”

“The fire drill held on 7/29/22 did not include evacuation of all residents; 41 residents were present but only 39 evacuated, with one resident not evacuating due to COVID-19 and one sleeping through the drill. No additional drill was held in July 2022 to ensure all residents could evacuate.”