Oakbridge Terrace at Spring House Estates.

“Three incidents involving allegations of inappropriate sexual behaviors or abuse were not reported to the Local Area Agency on Aging. The incidents occurred on unspecified dates at approximately 3:00 PM (involving residents and witnessed by staff person A), approximately 3:00 PM (witnessed by staff person B and reported to staff person C), and at 7:01 PM (witnessed by staff person D and reported to staff person E).”

“The residence failed to report four incidents to the Department within 24 hours: three incidents involving allegations of inappropriate sexual behaviors or abuse (occurring at approximately 3:00 PM on two occasions and at 7:01 PM), and one incident where local police arrived on site in response to a resident's inappropriate behaviors towards other residents.”

“Resident medications labeled with personal medical information were unlocked, unattended, and accessible on top of a medication cart by the front door of the East wing at 9:09 AM. At 9:12 AM, a medication cabinet in the same wing containing resident medications with personal medical information was also unlocked, unattended, and accessible to residents. This was a repeat violation.”

“A resident in the secure unit with minimal documented memory needs and a diagnosis questioned by medical professionals was required to sign an agreement with expectations including refraining from touching others and demonstrating appropriate behavior, with incentives tied to social activities. This resident, aware of behavioral expectations, repeatedly engaged in inappropriate sexual contact with cognitively impaired residents, including three documented incidents involving unwanted physical contact, gesturing, and attempted solicitation of residents unable to consent.”

“Resident #1's face sheet/discharge transfer sheet containing medications and health information was unlocked, unattended, and accessible in a shared office in the special care unit, violating confidentiality requirements.”

“Direct Care Staff Person A received only 14.89 hours of annual training relating to job duties during training year January 1, 2024 to December 31, 2024, falling short of the required minimum of 16 hours.”

“The bathroom in resident living unit 212 had a strong odor, a brown stain on the floor, and a brown substance on the outside of the toilet bowl that appeared to be feces, failing to maintain sanitary conditions.”

“The bathroom in resident living unit 212 does not have an operable window and the ventilation fan is inoperable, failing to provide adequate bathroom ventilation.”

“A cat present at the residence does not have a current certificate of rabies vaccination; the most recent vaccination was 6/10/21 and expired 6/10/22.”

“Resident #2's most recent medical evaluation was not completed within the required annual timeframe, as the resident was not in the home during the scheduled annual medical evaluation.”

“The first aid kit in the van used to transport residents does not include a thermometer, as required by regulation.”

“Trash outside the home was not kept in covered receptacles. A cardboard box with a white plastic bag containing trash was found near the covered dumpster, allowing potential penetration of insects and rodents.”

“Food requiring refrigeration was not stored at proper temperature. The ice cream freezer temperature was 12 degrees Fahrenheit instead of the required 0°F or below.”

“Fire drills were not held on different days of the week and at different times as required. Monthly fire drills were held on Thursday for three consecutive months (March 7, April 11, and May 30, 2024).”

“Prescription medications were not stored in accordance with manufacturer's instructions. Humalog 100 unit/ml vial prescribed for resident #2 with a discard-after date of 08/03/2024 was still in the medication cart on 08/13/2024.”

“Medical evaluation documentation for a resident in the special care unit for Alzheimer's disease or dementia did not include the resident's diagnosis of dementia and the need for placement in the special care unit. This was a repeat violation from 06/26/2023.”

“Resident #1's medical evaluation does not indicate a diagnosis of Alzheimer's disease or dementia and the need for the resident to be served in a special care unit. Resident #2's medical evaluation does not indicate a diagnosis of Alzheimer's disease or dementia and the need for the resident to be served in a special care unit.”

“Resident #1 was admitted to the special care unit but the written cognitive preadmission screening states the resident has no diagnosis of dementia and the resident's needs cannot be met by the residence. Resident #2 was admitted to the special care unit but the written cognitive preadmission screening states the resident does not require the services of a special care unit.”

“Resident #1, who does not have a primary diagnosis of Alzheimer's disease or other dementia or brain injury, was admitted to the special care unit and does not have a spouse, friend or family member living on the unit. Resident #2, who does not have a primary diagnosis of Alzheimer's disease or other dementia or brain injury, was admitted to the special care unit and does not have a spouse, friend or family member living on the unit.”