Sherwood Oaks.

“Facility failed to immediately report suspected abuse to the local Area Agency on Aging. A resident became locked in a bathroom after an incident with staff; the allegation was not reported to the Area Agency on Aging until after the Department's inspection, though it was reported to Butler County Protective Services on 12/2/2024.”

“Facility failed to immediately submit a plan of supervision or notice of suspension to the Department for staff person A involved in the alleged abuse incident. Staff person A was not suspended or placed on a plan of supervision until after the Department's inspection.”

“Facility failed to report the incident involving suspected abuse to the Department's personal care home regional office within 24 hours. The allegation of abuse was not reported to the Department until after the inspection began.”

“A resident in the secured dementia care unit was not adequately protected from neglect. The resident, who requires prompting for ambulation and uses a rollator, was left unsupervised in a locked bathroom after an incident with staff, creating a potential safety hazard.”

“Direct care staff person A provided unsupervised ADL services on multiple dates (10/22/24, 10/23/24, 10/24/24) from 11:00 p.m. to 7:00 a.m. without having successfully completed the Department-approved direct care training course or passing the competency test.”

“The soiled utility room door on the second floor of the secured dementia care unit was wide open with three aerosol cans containing disinfecting spray and one quart bottle containing Banish Urinal and Toilet Cleaner (Hydrochloric Acid) unlocked, accessible, and unattended. Not all residents in the secure dementia care unit were assessed to be safe around poisonous and hazardous materials.”

“Resident #1's medical evaluation was not completed within the required annual timeframe; the next evaluation was not completed until a date significantly after the one-year anniversary.”

“There was no code visible for the locking mechanism for the gate leading out of the outside garden, and there was no code posted for the door leading from the outside garden on the first floor into the dining room of the first floor secured dementia care unit.”

“Two black packages of pre-pureed foods were found on the floor of the walk-in freezer in the kitchen, with one package partially unsealed, violating sanitary conditions requirements.”

“The right lid of the furthest right dumpster at the grounds department was pushed inward against the rear wall, creating an opening of approximately 2.5 by 4 feet and preventing the receptacle from being fully covered.”

“The continuous air draw vent in the private bathroom located in a resident room was not operational and there was no window in the bathroom, violating ventilation requirements.”

“A resident in a private room did not have access to a bedside source of light that could be turned on from bed, as required by regulation.”

“A stainless-steel tray of partially covered shredded Swiss cheese and a stainless-steel tray of partially covered tilapia were found in the walk-in refrigerator with inadequate sealing at the edges, violating food storage requirements.”

“A resident's prescribed medication had a pharmacy label that indicated incorrect dosing instructions (daily at bedtime instead of the prescribed schedule), creating a medication safety risk.”