Inspection Reports for Oak Leaf Manor Personal Care Retirement Home
2101 WABANK ROAD,, MILLERSVILLE, PA, 17551
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
67% occupied
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 55
Capacity: 82
Deficiencies: 12
Date: Oct 17, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons on 10/17/2024 and 10/18/2024.
Findings
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.
Deficiencies (12)
Residents admitted prior to change of legal entity had not completed new contracts with the new legal entity.
Direct care staff person received only 11.70 hours of annual training in 2023, less than the required 12 hours.
Poisonous materials were not stored in original labeled containers; carpet stain cleaner was in a bottle labeled 'Glass Cleaner'.
Trash can in public bathroom in Secure Dementia Care Unit was uncovered.
OTC medications were unlocked, unattended, and accessible in a resident's bathroom vanity cabinet.
Loose pills and expired medication were found in the Secure Dementia Care Unit medication cart.
OTC medications and CAM were not labeled with the resident's name in the Secure Dementia Care Unit medication cart.
Medications prescribed to residents were not available in the home as ordered.
Medication administration record did not include all necessary directions; printed MARs lacked additional directions.
Medications prescribed to residents were not administered as ordered.
Medication error was not immediately reported to the resident, designated person, or prescriber.
Directions for operation of key locking devices were not conspicuously posted near the devices in the Secure Dementia Care Unit.
Report Facts
License Capacity: 82
Residents Served: 55
Secured Dementia Care Unit Capacity: 43
Residents Served in Secured Dementia Care Unit: 17
Current Hospice Residents: 2
Direct Care Staff Training Hours: 11.7
Total Daily Staff: 81
Waking Staff: 61
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 20, 2023
Visit Reason
The inspection visit occurred due to a change in legal entity for the facility.
Findings
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.
Deficiencies (2)
Uncovered enabler bar with an opening greater than 4 ¾ inches posing an entrapment hazard in Resident Room #B13.
Unlocked poisonous materials accessible in the hallway bathroom and kitchenette of the secured dementia care unit, posing a safety risk to residents incapable of recognizing poisons.
Report Facts
Residents Served: 53
Capacity: 43
Residents Served: 20
Current Residents: 3
Residents 60 Years or Older: 52
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 29
Resident Support Staff: 0
Total Daily Staff: 82
Waking Staff: 62
Inspection Report
Original Licensing
Census: 53
Capacity: 82
Deficiencies: 2
Date: Jul 20, 2023
Visit Reason
The inspection was conducted due to a change in legal entity and as part of the initial licensing process for Oak Leaf Manor Personal Care Retirement Home.
Findings
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.
Deficiencies (2)
Uncovered enabler bar with an opening greater than 4 ¾ inches in Resident Room #B13 posing an entrapment hazard.
Unlocked, unattended, and accessible poisonous materials including a tube of Remedy Protectant Z Guard Paste and two bottles of surface cleaners in the secured dementia care unit.
Report Facts
License Capacity: 82
Residents Served: 53
Capacity of Secure Dementia Care Unit: 43
Residents Served in Secure Dementia Care Unit: 20
Total Daily Staff: 82
Waking Staff: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the licensing letter and certificate. |
| Maintenance Director | Named in plan of correction for removing poisonous materials and fixing kitchenette door. | |
| Executive Director | Named in plan of correction for auditing enabler bars and poisonous materials, and creating training documents. | |
| Memory Care Coordinator | Responsible for weekly audits of enabler bars and poisonous materials. | |
| Laundry Aide | Covered the uncovered enabler bar immediately following inspection. |
Notice
Capacity: 82
Deficiencies: 0
Date: May 21, 2021
Visit Reason
The document is a license renewal notification and certificate of compliance issued in response to the facility's renewal application to operate a Personal Care Home.
Findings
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.
Report Facts
Maximum capacity: 82
Secure Dementia Care Unit capacity: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trisha L. Johnson | LPN / PCHA | Recipient of the renewal notification letter |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signer of the renewal notification letter |
Inspection Report
Renewal
Census: 58
Capacity: 82
Deficiencies: 0
Date: Apr 14, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of Oak Leaf Manor Personal Care Retirement Home on April 14-15, 2021.
Findings
No regulatory citations or deficiencies were identified during the inspection. The facility was found to be in compliance with all applicable regulations.
Report Facts
Residents Served: 58
License Capacity: 82
Staffing Hours: 85
Waking Staff: 64
Secured Dementia Care Unit Capacity: 43
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 2
Residents Age 60 or Older: 57
Residents with Mobility Need: 27
Residents with Physical Disability: 2
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