Inspection Reports for
Oakwood Terrace

The facility was found to have fully implemented the submitted plan of correction related to resident abuse and elopement reporting. Improvements included timely written reporting, staff training, environmental safety checks, and ongoing audits to ensure compliance.

The facility was found to have fully implemented the plan of correction related to an abuse incident and medical evaluation deficiencies. Staff received retraining, policies were updated, and audits were established to ensure ongoing compliance.

The inspection was complaint-driven, as noted under Inspection Information with Reason: Complaint. The plan of correction was accepted and fully implemented as of 03/23/2026.

The facility was found to have deficiencies related to snow and ice removal from emergency exits, incomplete preadmission screening forms, delayed resident assessments, and incomplete support plan revisions. The submitted plan of correction was accepted and fully implemented.

No regulatory citations or deficiencies were identified during the inspection.

The facility was found to have deficiencies related to failure to immediately report suspected resident abuse, failure to timely report a serious injury incident, and incomplete resident assessments. The submitted plan of correction was accepted and fully implemented, with ongoing audits and staff training to ensure compliance.

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

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

The inspection identified several deficiencies including unlabeled and undated leftover food, uncovered food storage, missing rabies vaccination documentation for a dog on site, and an inaccurate glucometer reading transcription. Plans of correction were accepted and implemented by 06/03/2025 with policies updated and staff training conducted to ensure compliance.

The facility was found to have fully implemented the plan of correction related to fire alarm false alarms and resident support plan documentation for evacuation needs and mobility. Compliance with applicable health and safety laws was addressed, including replacement of faulty smoke detectors and updating resident evacuation plans.

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

The inspection was complaint-related, provisional, and incident-based as stated in the inspection information section.

The inspection identified multiple deficiencies including record confidentiality breaches, compliance with health and safety laws, contract signature issues, staff training deficiencies, emergency telephone number postings, food labeling and storage violations, medical evaluation documentation issues, medication labeling and availability problems, resident rights education gaps, support plan inaccuracies, and missing instructions for key locking devices. All deficiencies had plans of correction accepted and were implemented by late October 2024.

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

The facility was found to have multiple violations related to resident abuse reporting, staff sleeping on duty, treatment of residents with dignity and respect, awake staff requirements, and incomplete resident support plans. The submitted plan of correction was fully implemented and compliance was maintained.

The submitted plan of correction was determined to be fully implemented as of the inspection date. The report details incidents involving resident abuse and treatment violations, as well as deficiencies related to support plan signatures, all of which had corrective actions directed and implemented.

The complaint investigation included incidents of resident-to-resident abuse, failure to report incidents timely, medication errors, and deficiencies in resident care plans and staff training. Substantiation status is not explicitly stated.

Multiple deficiencies were found including failure to post inspection summaries, confidentiality breaches, lack of quality management meetings, privacy violations, inadequate staff training including CPR and abuse reporting, medication administration errors, unsafe hot water temperature, incomplete first aid kits, failure to conduct required fire drills, smoking area hazards, and incomplete or inaccurate resident assessments and support plans.

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

The submitted plan of correction was determined to be fully implemented, with continued compliance required. The report details a repeated violation involving resident-to-resident altercation and outlines corrective actions including updated resident assessments and increased supervision.

Multiple violations were found related to medical evaluations, medication labeling and administration, storage procedures, prescriber order compliance, and resident assessments. The facility's certificate of compliance was revoked and replaced with a first provisional license contingent on correction of violations. Directed plans of correction were issued with deadlines for compliance.

The inspection identified multiple deficiencies related to medical evaluations, medication management, staff training, resident assessments, incident reporting, and quality management. Several repeated violations were noted, and plans of correction were directed or accepted with specified completion dates.

The submitted plan of correction was determined to be fully implemented. Deficiencies involved timely reporting of incidents, treatment of residents with dignity, annual medical evaluations, prohibition of restraints, additional assessments, and support plan signatures.

The visit was related to an incident complaint. The plan of correction was accepted and fully implemented. The report does not explicitly state substantiation status but indicates corrective actions were taken.

The facility was found to have fully implemented the submitted plan of correction related to abuse reporting and resident abuse incidents. The report details two repeat violations involving failure to report abuse timely and physical abuse by a staff member, both of which have been addressed with staff coaching, suspension, termination, and ongoing quality assurance measures.

The facility was found to have fully implemented the submitted plan of correction related to resident abuse reporting, incident reporting, and updating resident support plans. The violations involved delayed reporting of resident abuse and incomplete updates to resident support plans, all of which were corrected by the follow-up date.

The submitted plan of correction was found to be fully implemented. Several deficiencies were identified related to soap dispensers, locking devices, fire drill scheduling, medication storage and labeling, prescriber order compliance, and resident record content, all of which were addressed with corrective actions and accepted plans of correction.

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

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

The facility was found to have multiple deficiencies including failure to timely report incidents, inadequate staffing levels for resident needs, medication administration errors, and incomplete resident support plans. The submitted plan of correction was determined to be fully implemented as of the follow-up.

The visit was complaint-related. The submitted plan of correction was fully implemented as of the inspection date.

The facility failed to complete a resident's regularly scheduled CBC blood work required to maintain medication refills for Clonzapine. A plan of correction was submitted and determined to be fully implemented.

The inspection identified multiple deficiencies including unsigned resident contracts, improper food storage, obstructed egress due to a maglock on a door, incomplete medical evaluations, missing weekly menus, medication administration and storage issues, and documentation errors. Plans of correction were accepted for all deficiencies with follow-up documentation and audits required.

The submitted plan of correction was determined to be fully implemented. The incident involved inappropriate behavior between residents, and corrective actions including resident separation, monitoring, staff education, and behavior checks were completed.

No regulatory citations were identified as a result of these inspections.

The visit was complaint-related and incident-based. The complaint involved failure to timely report an incident involving a resident's hospitalization and death. The complaint was substantiated with findings of delayed incident reporting and documentation deficiencies.

The facility was found to have deficiencies related to delayed incident reporting, incomplete medical evaluation documentation, and incomplete preadmission screening forms. Plans of correction were accepted and implemented to address these issues.

The inspection was triggered by a complaint, and the visit was a partial unannounced inspection to follow up on the complaint.

Two deficiencies were identified: one involving an incomplete medical evaluation form missing the physician's signature and license number, and another where a resident's support plan was not updated to reflect hospice care. Both deficiencies were accepted with plans of correction implemented.

The submitted plan of correction was determined to be fully implemented. The facility was found to have addressed issues related to resident abuse reporting, incident reporting, medical evaluations, and support plan updates. Continued compliance must be maintained.

The facility was found to be in compliance after corrections were made following the inspection. Deficiencies included missing diagnosis or purpose on medication records, outdated resident support plans reflecting health declines, and incomplete admission support plans for the secured dementia care unit. Plans of correction were accepted and implemented.

The inspection was complaint-driven and identified repeated violations related to medication administration documentation and adherence to prescriber orders. Plans of correction were directed and verified as implemented.

The inspection identified repeated medication administration record violations related to documentation of PRN medication effectiveness and failure to follow prescriber's orders regarding medication administration parameters. Plans of correction were directed and subsequently implemented.

The inspection was complaint-driven, triggered by allegations of abuse and privacy violations. The financial exploitation by Staff B was substantiated with police involvement and photographic evidence. Staff A was disciplined for privacy violations. The plan of correction was accepted and implemented.

The inspection identified multiple deficiencies including financial exploitation of a resident by staff, privacy violations involving unauthorized photography, and incomplete or missing documentation related to medical evaluations, preadmission screenings, and support plans for residents in the secured dementia care unit.

No regulatory citations or deficiencies were identified as a result of the inspections conducted between 03/31/2020 and 06/26/2020.

The inspection was triggered by a complaint and incident. The submitted plan of correction was reviewed and found fully implemented as of September 3, 2021.

The facility was found to have violations related to pre-admission screening, support plan refusal signatures, and cognitive pre-admission screening. Plans of correction were submitted and later determined to be fully implemented.

The inspection was conducted due to a complaint or incident. The submitted plan of correction was reviewed and found fully implemented as of May 20, 2020.

The facility had multiple deficiencies related to incomplete medical evaluations, missing annual assessments, and outdated resident support plans. Plans of correction were submitted and verified as fully implemented.

The inspection was triggered by a complaint/incident. The investigation found substantiated staffing violations including inadequate administrator hours, insufficient staff in the memory care unit, and lack of trained staff in first aid and CPR.

The facility was found to have staffing deficiencies including lack of a qualified administrator working 20 hours per week, inadequate staffing levels in the memory care unit, and insufficient staff trained in first aid and CPR. Plans of correction were submitted and fully implemented by March 19, 2020.

The inspection was complaint-related with substantiated findings including resident abuse and multiple regulatory violations.

Multiple violations were found including resident abuse, unsafe equipment, sanitary issues, lack of hot water, inadequate soap dispensers, insufficient towels, prohibited space heaters, medication storage problems, and incomplete resident support plans. Plans of correction were implemented and approved.

Complaint investigation with substantiated findings of abuse, medication errors, inadequate staffing, and failure to report incidents.

The facility was found deficient in multiple areas including abuse reporting, incident reporting, medication administration, staffing, training, sanitary conditions, and documentation. Plans of correction were submitted and partially implemented with ongoing monitoring.

No inspection findings are reported in this document. It states that an onsite inspection will be conducted within the next twelve months and enforcement actions may follow if noncompliance is found.

The visit was complaint-related due to an allegation of abuse against staff persons A and B regarding resident #1. The home suspended staff but failed to follow proper notification and approval procedures. The plan of correction was partially implemented as of January 13, 2020.

The facility failed to submit a plan of supervision or notice of suspension for staff involved in the abuse allegation and did not notify the Department with the final investigation report before allowing staff to return to work. The home also failed to wait for Regional Office approval before reinstating suspended staff.

The complaint involved verbal abuse by staff person A toward resident #1. The allegation was substantiated as staff person A was suspended but returned without required supervision. Unauthorized video recording was also found.

The investigation found that staff person A verbally abused a resident and was suspended but later allowed to return to work unsupervised without submitting a required plan of supervision. Additionally, unauthorized video recording of common areas occurred, violating resident privacy.

The inspection identified multiple violations related to facility conditions, food safety, medication storage, and medication administration records. Plans of correction were submitted and partially implemented with adequate progress noted as of February 22, 2019.

No inspection findings are reported in this document. It primarily communicates the renewal application receipt and licensing issuance for Oakwood Terrace.

The inspection identified violations related to missing fee schedules in resident contracts, lack of required annual training on medication self-administration for direct care staff, and incorrect documentation of alternate exit routes during monthly fire drills. Plans of correction were submitted and partially implemented with adequate progress as of December 18, 2017.

No inspection findings are reported in this document. It confirms issuance of a regular license and outlines the Department's obligation to conduct annual inspections.

The complaint involved suspected abuse reported on 6/15/17 where a resident was injured by another resident. The home did not report the incident to the local Area Agency on Aging as required. The incident was investigated and substantiated.

The facility failed to immediately report suspected abuse of a resident as required by regulations. The incident involved bodily injury and was not reported to the local Area Agency on Aging.

The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the new legal entity status.