Inspection Reports for
Oak Leaf Manor Personal Care Retirement Home

No regulatory citations or deficiencies were identified during this inspection.

The inspection identified multiple deficiencies including failure to report suspected resident abuse timely, improper food storage, inadequate fire drill scheduling, medication storage and labeling issues, failure to follow prescriber's orders, and documentation deficiencies. The facility submitted plans of correction and demonstrated implementation of corrective actions.

The inspection was triggered by a complaint. The report documents substantiated deficiencies related to neglect, medication errors, training deficiencies, and incomplete resident documentation.

Multiple deficiencies were identified including failure to report an incident of alleged neglect, unsecured medications accessible to residents, staff not completing required medication administration training, incomplete resident assessments, and missing required documentation such as current resident photographs. Plans of correction were accepted and implemented by December 1, 2025.

The facility was found to have multiple deficiencies including issues with written resident contracts after a legal entity change, staff training hours, improper labeling and storage of poisonous materials and medications, unlocked medications, expired and unlabeled medications, missing medication administration, medication error reporting failures, uncovered trash receptacles, and missing directions for key locking devices. Plans of correction were accepted and implemented for all deficiencies.

The submitted plan of correction was determined to be fully implemented. Two deficiencies were noted: an uncovered enabler bar posing an entrapment hazard, and poisonous materials being unlocked and accessible in the secured dementia care unit. Both issues were corrected promptly with audits, training, and physical modifications to ensure safety.

The facility was found to be in substantial compliance with applicable regulations. Two deficiencies were cited related to resident personal equipment and locking poisonous materials, both of which had corrective plans accepted and implemented.

The waiver permits the administrator to serve while enrolled in the required 100-hour training course and mandates passing a competency-based test. Supervision by a qualified administrator is required until compliance is met.

The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.

No regulatory citations or deficiencies were identified during the inspection. The facility was found to be in compliance with all applicable regulations.

No inspection findings are reported in this document; it serves as a license renewal notification and certificate of compliance.

No regulatory citations with 55 Pa. Code Ch. 2600 relating to Personal Care Homes were identified as a result of this inspection.

The complaint investigation was substantiated based on observed resident abuse incidents and medication administration errors involving Resident 1. The facility was required to implement corrective actions.

The investigation found violations related to resident abuse, failure to follow prescriber's orders, and inadequate support plan revisions. The facility implemented a plan of correction including increased supervision, staff training, medication audits, and support plan audits.

The inspection identified multiple violations related to personal care home regulations including insufficient emergency drinking water supply, unsecured medications, expired prescriptions, incomplete preadmission screening documentation, and missing resident record content. Plans of correction were submitted and partially implemented with adequate progress noted.

No inspection findings are reported in this document as it is a renewal notice and license certificate.

The inspection was complaint-driven. Specific issues involved incomplete resident assessments and missing signatures on support plans. Resident #1's family requested a higher level of care due to concerns.

The inspection found violations related to resident assessments and support plan documentation. The facility had not completed a new assessment reflecting changes for a resident and a resident did not sign their support plan.

Multiple violations of 55 Pa.Code Chapter 2600 were found, including unsecured poisonous materials, inadequate emergency water supply, prohibited portable space heaters, outdated fire safety inspection, and incomplete medication administration documentation. Plans of correction were submitted and partially or fully implemented by July 2018.

No inspection findings are reported in this document. It is a license renewal notice with an enclosed certificate of compliance.

Violations were found related to the facility's resident contract fee schedule, specifically the contract did not specify a fee schedule listing the actual amount of allowable resident charges for services. A plan of correction was submitted and partially implemented as of the approval date.

The facility was found to be in substantial compliance with the regulations set forth in 55 Pa.Code Chapter 2600 relating to Personal Care Homes. The licensing inspector was unable to complete a full inspection due to the newness of the legal entity.