Cole Manor

The home failed to report an incident where a resident was unable to receive prescribed Hydrocodone because it was not present in the home.

A laptop containing a resident's medication record was left unattended and accessible on a medication cart.

A staff member refused to administer prescribed pain medication to a resident and used intimidating language.

Unannounced fire drills were not conducted during the months of March and April 2025.

Prescribed Hydrocodone was unavailable in the home for a resident for several days.

An incident report regarding a resident fall was not submitted to the Department within the required 24-hour timeframe.

An enabler bar in a resident's room was not secured firmly to the bed and moved freely.

A resident's bedroom lacked an operable lamp or bedside light source.

The home failed to conduct a required monthly unannounced fire drill in November 2024.

The annual fire safety inspection and supervised fire drill had not been completed within the required timeframe.

A recent fire drill evacuation time of 3 minutes 44 seconds exceeded the 2 minute 50 second limit set by the fire safety expert.

No staff members were first aid trained and certified in the home between 4 PM and 6 AM.

The last fire drill conducted during sleeping hours was performed on 5/21/23, exceeding the 6-month requirement.

A resident's medical evaluation form was reformatted, causing missing required fields such as diet and medication self-administration.

A resident's initial support plan was not completed within the required 30 days of admission.

Resident #1 was administered medication at a frequency that did not follow the prescriber's orders.

Staff used Lorazepam to subdue an agitated resident, which constitutes a prohibited chemical restraint.

The resident's support plan failed to document physician-ordered physical, occupational, and speech therapies.

Incidents involving medication issues were not reported to the Department within the required 24-hour timeframe.

A staff member failed to complete required orientation training on the Emergency Medical Plan within 40 scheduled working hours.

Direct care staff members were providing unsupervised ADL services before completing the required direct care training course.

The resident-home contract for Resident #1 was not signed by the resident.

Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.