Oak Leaf Manor North.

“The home failed to report a reportable incident to the Department within 24 hours. A resident was admitted to Lancaster General Hospital with a diagnosis involving a lesion on the scalp after maggots and eggs were discovered; the resident was discharged with instructions for continued IV antibiotic administration. The home did not report this incident to the Department.”

“Poisonous materials (19oz. can of Lysol and 24 fl. oz. bottle of Clorox toilet bowl cleaner) were kept in an unlocked, unattended housekeeping cart accessible to residents in the secured dementia care unit. Not all residents in the unit had been assessed as capable of recognizing and using poisons safely.”

“A walker and several window screens blocked the egress of the home's rear stairwell exit from the secured dementia care unit, obstructing an emergency exit route.”

“A resident's medical evaluation did not include the resident's medical diagnosis or medical treatment pertinent to the diagnosis. This is a repeated violation.”

“The home did not have a process in place to ensure that treatments provided by outside agencies were properly provided and documented in the resident's record. Multiple treatment instruction sets were received from Bayada Home Health Services and Penn Med regarding wound care but were not tracked or verified as being administered and documented.”

“A resident's Medication Administration Record for September 2025 did not include the initials of the staff person who administered a prescribed blood pressure medication on a specific date and time (21:33).”

“Resident was involved in physical altercations with other residents on 12/28/24 at approximately 3:13 PM, on 1/6/25 at approximately 10:07 PM, and on 1/9/25 at approximately 9:45 AM. However, these incidents of abuse were not reported to the local area agency on aging.”

“Resident was involved in physical altercations with other residents on 12/28/24, 1/6/25, and 1/9/25 that were not reported to the Department within 24 hours. Additionally, on an unspecified date, resident had physical altercations at approximately 2:40 PM and 3:30 PM that were not reported to the Department timely.”

“Multiple incidents of resident-to-resident abuse occurred: on an unspecified date at approximately 2:40 PM, one resident grabbed another by the hair causing hair loss; at approximately 3:30 PM, one resident struck another on the arm and face causing a red mark; and on a second shift, one resident shoved another and pulled hair while the second resident bit the first on the wrist, both sustaining bruising.”

“A resident's support plan was completed on an earlier date; however, between that date and the inspection date, the resident exhibited significant behavioral changes resulting in multiple physical altercations with staff and other residents, but the support plan was not updated to reflect these changes.”

“A resident was observed being forcibly pulled into a wheelchair by Staff Member A during a Christmas Party in December 2023. This allegation of abuse was not reported to the Local Area Agency on Aging as required.”

“An incident in December 2023 where a resident was forcibly pulled into a wheelchair by Staff Member A was not reported to the Department within 24 hours as required.”

“Multiple incidents of abuse were substantiated: Staff Member A forcibly pushed a resident's wheelchair and pulled it back repeatedly; a resident struck another resident in the back with a closed fist; residents engaged in physical altercations with kicking and hitting; a resident grabbed another by the forearm causing marks; and a resident bit another resident's finger. Staff Member A was suspended and terminated due to resident abuse.”

“Staff Member G, who had not successfully completed a Department-approved medication administration course, administered medications to residents including tablets and capsules by mouth on multiple dates.”

“A resident was admitted to the Secure Dementia Care Unit but the medical evaluation was not completed within 60 days prior to admission. Another resident's medical evaluations did not include documentation of a diagnosis of Alzheimer's disease or other dementia and the need for service in a secured dementia care unit.”

“The first aid kit in the facility bus used for resident transportation was missing required contents: thermometer, tweezers, and eye coverings.”

“Dryer 1 in the 1st floor secure dementia care unit had a thick accumulation of lint in the lint trap, creating a fire hazard.”

“Two resident cats did not have current rabies vaccination certificates from a licensed veterinarian on file.”

“The home did not post required Clean Indoor Air Act signs at entrances stating "Smoking Permitted in Designated Areas Only" or "No Smoking" as of the inspection date.”

“Four residents had contracts that pre-dated the legal entity change in 2023 and did not reflect the current operating company.”

“Staff Member A engaged in multiple incidents of verbal and physical abuse toward residents including belittling comments, intentionally annoying residents, and physically grabbing and throwing Resident 10 into bed. This was a repeated violation from 09/25/2023.”

“The home failed to document in the resident's support plan the medical, dental, vision, hearing, mental health or other behavioral care services that will be made available to the resident, or referrals for services if needed. (Description incomplete in source document)”

“Incidents of resident-to-resident abuse occurred in the home on unspecified dates. Staff Member A confirmed that Act 13 Mandatory Abuse forms were not completed or submitted to the Area Agency on Aging (AAA).”

“Multiple incidents of resident-to-resident abuse occurred: Resident #1 punched Resident #3 in the face, punched Resident #2 in the chest (with Resident #2 retaliating), slapped Resident #4 in the face, shoved and hit Resident #5 in the back of the head, grabbed and shook Resident #6 by the neck, and placed a pillowcase over sleeping Resident #7's face. Resident #2 also smacked Resident #1 across the face, causing bleeding.”

“Staff Member B performed a manual restraint on Resident #1 on an unspecified date to reduce Resident #1's ability to move his/her arms, which is a prohibited procedure.”

“Resident #1 displays physical aggression toward residents and staff members and experiences hallucinations. The home failed to complete a new assessment when the resident's condition significantly changed. As of the inspection date, Resident #1's current RASP dated at an unspecified earlier date states Resident #1 has no problem with irritability, agitation, aggression or hallucinations, which contradicts the current presentation.”