Inspection Reports for
Oakwood Residence

The facility had multiple deficiencies including incomplete staff training records, stained ceiling tiles, food stored on the floor, punctured medication blister packs, and missing medication administration documentation. All deficiencies were addressed with corrective plans and verified as implemented.

The investigation was complaint-driven, focusing on allegations of neglect, failure to report abuse, inadequate care planning, medication errors, pain management deficiencies, and infection control breaches. The complaints were substantiated as the facility was found deficient in multiple areas.

The facility failed to timely report allegations of abuse and neglect, did not revise care plans promptly after falls, failed to provide adequate assistance with activities of daily living for multiple residents, did not follow physician orders for medication administration, failed to implement non-pharmacological pain management interventions, and did not adhere to infection control protocols related to PPE use on a nursing unit.

The complaint investigation found that the facility failed to ensure complete and accurate medication administration documentation for one of nine residents reviewed. The deficiency was substantiated with interviews and record reviews.

The facility failed to ensure complete and accurate documentation of medication administration for one of nine residents reviewed. Specifically, a licensed nurse administered Acetaminophen but did not document it in the medication administration record.

The inspection identified several deficiencies related to food storage, medication storage, medication availability, and documentation of blood glucose monitoring. The facility submitted plans of correction which were accepted and later determined to be fully implemented.

The facility was found deficient in multiple areas including failure to make survey results accessible to residents, maintain confidentiality of medical records, investigate abuse allegations, develop comprehensive care plans, provide timely vision and hearing services, ensure effective elopement interventions, provide appropriate respiratory care, maintain adequate staffing levels, address pharmacist medication irregularities, and implement infection prevention protocols.

The complaint was substantiated. Resident R1 reported that Employee E4 administered medications despite his request not to have her provide care. The Unit Manager confirmed that Employee E4 should not administer medications to Resident R1, but records showed Employee E4 administered medications on multiple days in March, April, and May 2024.

The facility failed to ensure that Resident R1's right to choose healthcare providers was respected, as Licensed Nurse Employee E4 administered medications to the resident multiple times despite the resident's explicit request not to have her provide care.

The complaint involved mental abuse allegations by Resident R48 against two nurse aides who were observed whistling and triggering the resident. The facility investigated and found one nurse aide denied the behavior, while the other did not provide a statement. The resident also reported prior incidents. Additional complaints included inadequate personal care, medication administration errors, infection control breaches, menu deficiencies, and equipment maintenance issues.

The facility was found to have multiple deficiencies including failure to accommodate resident preferences, inadequate personal care, improper administration of blood pressure medication outside physician orders, failure to follow infection control protocols, inadequate menu planning, and unsafe food service equipment maintenance.

The inspection found multiple deficiencies related to medication security, bathroom ventilation, lighting, food storage, refrigerator temperatures, unobstructed egress, combustible storage, fire drill scheduling, medication labeling, medication availability, and medication record keeping. All deficiencies had plans of correction accepted and were implemented by 12/11/2023.

The inspection identified multiple deficiencies including sanitary conditions, missing first aid kit items, improper refrigerator/freezer temperatures, lint accumulation in dryer, lack of posted activity calendar, and incomplete resident assessments and support plans. All deficiencies had plans of correction accepted and were documented as implemented.

No inspection findings are reported in this document. It confirms the issuance of a license and outlines the requirement for a future annual inspection to ensure compliance.

The submitted plan of correction was determined to be fully implemented. Two deficiencies were identified: one related to a resident-home contract not signed by the administrator or designee, and another related to incomplete medication administration training records for a staff person.

The Department determined that the submitted plan of correction was fully implemented and that continued compliance must be maintained.

No inspection findings are reported in this document. It informs the facility of the requirement for an annual onsite inspection within the next twelve months.

The submitted plan of correction was found to be fully implemented. The facility demonstrated compliance with posting influenza information, menu posting, and medication administration training requirements.

No regulatory citations or deficiencies were identified as a result of this inspection.

No inspection findings are reported in this document. It primarily communicates the renewal of the facility's license and the requirement for a future annual inspection.

Multiple violations of 55 Pa. Code Chapter 2600 were found, including sanitary conditions, uncovered trash cans, poor repair of ceilings and walls, lack of thermometer in freezer, incomplete medical evaluation documentation, failure to educate a resident on medication rights, and incomplete written description of services. Plans of correction were submitted with partial implementation status.

No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.

The inspection included a complaint investigation component, but the substantiation status is not stated.

The facility was found to have multiple violations related to safety equipment, medication storage and administration, and resident support plans. Plans of correction were submitted with partial implementation progress noted.

No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.

The complaint was regarding the home's elevator being out of service for more than one week. The complaint was substantiated by the inspection findings.

The facility failed to develop and implement written policies for reporting and managing incidents related to the elevator outage. Residents with mobility needs were restricted in their ability to leave and return to the home due to the elevator being out of service for multiple weeks.

The facility was found to be in compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.

No inspection findings are reported in this document. It serves as a license renewal notification and outlines the regulatory requirement for a future annual inspection.