Oak Leaf Manor Personal Care Retirement Home.

“Administrator failed to report an incident of alleged neglect to the Department within 24 hours. A resident with an order for medication every 3 hours as needed for pain did not receive the medication when requested by staff, despite staff notifying the Med-Tech of the need.”

“Prescription medications were found unlocked, unattended, and accessible in a resident's room. The resident's medical evaluation indicated the resident cannot self-administer medications.”

“Staff Person C administered prescription medications to residents without completing annual medication administration training requirements since initial certification.”

“Multiple staff members (Staff Members D, E, and F) administered insulin injections to residents without current completion of Department-approved diabetes patient education program within the past 12 months.”

“Resident assessments were not updated to reflect current care needs. One resident's assessment did not reflect the need for physical assistance with eating despite staff observations indicating this need. Another resident's assessment did not document the dietary need for a mechanical soft diet as indicated in the medical evaluation.”

“A resident's support plan did not document the use of a wheelchair despite the assessment indicating a need for assistance ambulating and the resident utilizing the wheelchair.”

“OTC medications were found unlocked, unattended, and accessible in Resident 4's bathroom vanity cabinet. Resident 4 is not assessed to self-administer medications. All prescription and OTC medications and syringes must be kept in a locked area or container.”

“Two residents admitted prior to a change of legal entity were not provided new written contracts with the new legal entity. The administrator failed to complete, review, and obtain signatures on updated resident-home contracts within the required timeframe.”

“Direct care Staff Person A received only 11.70 hours of annual training in training year 2023, falling short of the required minimum of 12 hours.”

“A bottle labeled with the manufacturer's label 'Glass Cleaner' was found in the chemical storage room containing carpet stain cleaner, as evidenced by 'Carpet Stain Cleaner' being handwritten on the bottle. Poisonous materials must be stored in their original, labeled containers.”

“An uncovered trash can with waste was located in the public bathroom in the Secure Dementia Care Unit. Trash in bathrooms must be kept in covered receptacles to prevent the penetration of insects and rodents.”

“Loose pills were observed in the A Hall medication cart. Additionally, an expired hand cream (expired May 2018) was located in the Secure Dementia Care Unit medication cart. Medications must be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light in accordance with manufacturer's instructions.”

“Hand cream medication located in the Secure Dementia Care Unit medication cart was not labeled with a resident's name. OTC medications and CAM belonging to residents must be identified with the resident's name.”

“An uncovered enabler bar with an opening greater than 4¾ inches was found in Resident Room #B13, posing an entrapment hazard.”

“A tube of Remedyl protectant Z guard paste and 2 bottles of Signet surface cleaners with warning labels were found unlocked, unattended, and accessible in the hallway bathroom and kitchenette of the secured dementia care unit, where residents are incapable of recognizing and using poisons safely.”

“An uncovered enabler bar with an opening greater than 4¾ inches was found in Resident Room #B13, posing an entrapment hazard to residents.”

“A tube of toothpaste and 2 bottles of Signet surface cleaners with hazard warnings were unlocked, unattended, and accessible in the hallway bathroom and kitchenette of the secured dementia care unit where residents are incapable of recognizing and using poisons safely. Additionally, the kitchenette door could be pushed open with force while locked.”