Inspection Reports for
Oak Park Estates AL & Memory Care

481-69.32(4)b Life Safety - Emergency Policies / Structure: The program failed to develop and implement written procedures addressing appropriate staff response when a tenant's service plan indicated a risk of elopement or wandering behavior for Tenant #3. The tenant exhibited wandering behavior and elopement risk was identified without corresponding written procedures in place.

481-67.2(3) Program Policies and Procedures: The program failed to follow its medication administration policy as medications and extra medications were not secured properly in the medication room.

481-67.5(2)f(4) Medications: Staff administered Miralax to tenants in 3 oz cups mixed with water instead of the ordered 8 oz of liquid, and a medication was given after the meal instead of before as prescribed.

481-67.5(2)f(4) Medications: The program failed to document and administer compression stockings as ordered for Tenant C2, and Miralax was not mixed properly as required.

481-67.9(4)b Staffing: The program failed to ensure staff received nurse delegation training within 30 days of employment for 5 of 5 unlicensed direct care staff reviewed.

481-69.25(1)i Tenant Documents: The program failed to document nurse notes by exception for 2 current tenants and 2 discharged tenants, including incomplete medication administration records and missing documentation of wound treatment.

481-69.25(1)i Tenant Documents: Nurse notes were incomplete regarding wound care, hospitalizations, and medication refusals for multiple tenants.

481-69.28(5)a(1)(2)(3) Food Service: The program failed to provide food safety training for staff responsible for food preparation and service, and failed to ensure food was held at safe temperatures, with inconsistent temperature documentation.

481-69.28(8) Food Service: The program failed to ensure all perishable and potentially hazardous foods were cooked and held at safe temperatures, potentially affecting all tenants.

481-69.39(4) Respite Care Services: The program failed to provide written direction to staff and document care needs for a discharged respite tenant, including inadequate supervision and failure to address safety and medical needs.

481-67.3(2) Tenant Rights: The program failed to ensure 1 of 7 tenants reviewed received adequate and appropriate services as Tenant #5 refused shower assistance and staff had no directives on how to assist her.

481-67.9(6) Staffing: The program failed to ensure 4 of 9 staff members completed dependent adult abuse training within six months of employment as required by Iowa Code section 235B.16.

481-69.22(3) Evaluation of Tenant: The program failed to complete evaluations as needed for 2 tenants who experienced significant changes prior to their return from hospitalization.

481-69.30(5) Dementia Specific Education for Personnel: The program failed to ensure 5 of 9 staff members received 8 hours of dementia-specific training that included hands-on instruction.

481-67.9(6) Staffing: The program failed to ensure staff received training relating to the identification and reporting of dependent adult abuse as required. One of three staff reviewed had no documentation of dependent adult abuse training within six months of employment.

481-67.19(3) Record Checks: The program failed to ensure background checks were completed prior to employment for one of three staff reviewed. The nurse could not locate the employee's background checks via email.

481-69.30(1) Dementia Specific Education for Personnel: The program failed to ensure employees received a minimum of eight hours of dementia-specific training within 30 days of employment for two of three staff reviewed. Staff A and C received training but did not complete it within the required timeframe.