Oak Glen Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision and interventions for one of three residents reviewed for elopement (incident when a resident leaves the facility without authorization or supervision necessary for safety) (Resident 1), after the resident was identified as being at risk for wandering and elopement upon admission. This failure resulted in Resident 1 leaving the facility undetected on June 14, 2026, placing the resident at risk for accidents, serious injury, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' room temperatures were monitored and recorded for three days in July 2025. This failure had the potential to prevent the facility from identifying whether the air conditioning system was functioning properly, which could result in residents experiencing discomfort or unsafe heat-related conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Crumbs and debris were found on the floor under the storage shelves in the storeroom; 2. Four clear food storage container had white debris on the top lid; 3. Four multiple canned goods white residue on it; 4. A walk- in refrigerator had dried dark red residue, crumbs and grime were on the floor; 5. The freezer in the disaster supply room had crumbs, and grime on its side and back; 6. Crumbs and debris found under the shelves in the disaster supply room; 7. One fan that was used in the kitchen had white debris on the blades and cover; and 8. Three Cutting boards were found without a smooth surface. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure multiple unused non-controlled medications were disposed in accordance with the policy and procedure. The medication disposition was not witnessed by two staff. This failure had the potential for medication diversion (the removal of a prescription drug from its intended path from the manufacturer to the patient).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. There was no signage for Enhanced Barrier Precaution (EBP) posted near Resident 40's room. In addition, there was no available personal protective equipment (PPE) supplies for the staff near the resident's room on EBP. 2. Two empty medication bags were not discarded in accordance with the standard of practice; and 3. Two non-staff transporters did not follow the proper isolation precautions for Resident 107. These failures had the potential to result in cross contamination which could cause illnesses to a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure the following for two of six residents (Residents 5 and 15) reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment): 1. For Resident 5, the resident or the resident's representative had been provided information and education regarding the formulation of an AD; and 2. For Resident 15, a copy of the AD was available in the resident's record. These failures had the potential to lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents reviewed (Resident 159), was receiving oxygen treatment in accordance with the care plan developed by the facility. This failure had the potential for the staff to be unaware whether the resident is consistently receiving the appropriate supplemental oxygen which could negatively impact the resident's overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of two residents reviewed for nutrition (Resident 41). This failure had the potential for the resident to continue having weight loss due to the delay in provision of appropriate intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents reviewed for respiratory care (Resident 159) , received respiratory treatment in accordance with the physician order. This failure has the potential to result in Resident 159 not to receive the necessary oxygen treatment which could negatively impact the resident's already compromised health.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Complete baseline care plans (Initial care plans, including mental, physical & psychosocial care needs, based on current health status) within 48 hours of admission for two out of three sampled residents (Residents 1 and 2), and 2. Provide resident and/or resident representative a copy of their baseline care plans, for two out of three sampled residents (Residents 1 and 3). This failure had the potential to result in a lack of communication between staff and residents, leading to inconsistencies in delivery of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the transfer/discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman (LTC Ombudsman) for one of three sampled residents (Resident 1). This failure has the potential for the Ombudsman not to be able to advocate for the resident in protecting his rights from inappropriate transfer and discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable environment for the residents, when the temperature level for one of the four residents' rooms and in the facility hallway was above 81 degrees Fahrenheit (°F -temperature scale). This failure had the potential to cause discomfort, irritability, sleep disruption, and could lead to health problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored, prepared, and served under sanitary conditions when: 1. The fifteen pounds of bacon were thawed and were refrozen; and 2. There was no thawing log available for review in accordance to the facility's policy and procedure. These failures had the potential to result in food borne illnesses (illness that comes from eating contaminated food) to 56 medically vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary staff performed testing of the sanitizing solution according to manufacturer's instructions. This failure had the potential to cause foodborne illness (illness that comes from eating contaminated food) among the 56 vulnerable residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of 16 sampled residents (Resident 54), the call light was within the resident's reach. This failure had the potential to result in Resident 54 not being able to call for staff assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record readily accessible to the staff, for one of three residents reviewed for AD (Resident 49). This failure had the potential for Resident 49's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor the residents' wishes regarding their medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up Level II Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) evaluation from the appropriate State-Designated Authority (SDA) upon admission, for two of four residents (Residents 42 and 44). This failure had the potential for Residents 42 and 44 not to receive the services required in an appropriate setting as determined by the SDA.

Inspectors wroteBased on observation, interview, and record review, the facility failed for one of 16 residents reviewed for quality of care (Resident 10) to ensure resident was monitored for signs and symptoms of bleeding or bruising (discoloration and tenderness of the skin resulting from pooling of blood beneath the skin) and the physician was notified. This failure had the potential for delayed treatment and management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for a Fortified (a food that has extra nutrients added to it or has nutrients added that are not normally there) NAS (no added salt) Mechanical Soft with chopped meat- diet, for one of 16 residents (Resident 33). This failure had the potential to not meet the resident's nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed for one of seven residents (Resident 159), to accommodate Resident 159's food preference for no fish, when Resident 159 was served fish. This failure resulted in Resident 159's food preference not being honored, potentially leading to the resident not consuming the food served and having the potential for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that leftover food brought by visitors or family members was stored properly when the temperature of the refrigerator was at 44 degree F (Farenheit - unit of measurement). In addition, food found inside the refrigerator at the nurses' station was not labeled. This failure had the potential for residents to be exposed to foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two staff reviewed was offered the COVID-19 (a respiratory infection caused by a virus) vaccination and provided education regarding the benefits and risks of the COVID-19 vaccine. This failure had the potential for the staff not to have guidance and information regarding the COVID-19 vaccine.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's rights to be free from sexual abuse (non-consensual sexual contact of any type such as unwanted touching, groping or any other sexual activity forced upon a person without their consent) by a resident (Resident 1), for four of five sampled residents, (Residents 2, 3, 4, and 5), when the facility failed to reevaluate existing interventions to address Resident 1's inappropriate sexual behavior. This failure resulted in repeated incidents of inappropriate sexual behavior of Resident 1 towards multiple residents (Residents 2, 3, 4, and 5).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control policy and procedures for Covid-19 (a highly infectious respiratory illness) were implemented, for one of six employees reviewed, when: 1. For Certified Nurse Aide (CNA) 1, the Employee's Screening Sheet (a log that employees fill out to self-report temperature, hand hygiene, fever or chills, cough, short of breath/difficulty breathing, fatigue, muscle or body aches, head ache, sore throat, new loss of taste/smell, congestion/runny nose, nausea/vomiting, diarrhea, pink eye, not feeling well) was accurately completed. 2. The Dietary Supervisor (DS) was sent home when she had signs and symptoms of respiratory illness (body aches, headache, sore throat, cough, and runny nose) on January 9, 2024, and January 10, 2024; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. There was no thawing and handling system for frozen nutritional supplement drinks (health shake); 2. The ice machine was not cleaned and sanitized properly per manufacturer's guidance, and 3. The foodservice department had no system for ambient food (food that can be safely stored at room temperature in a sealed container, for example, canned tuna fish) cooling down process. These failures had potential to cause foodborne illness in a highly susceptible population of 50 out of total census of 50 residents who received food from the kitchen of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors. One out of two garbage disposal bins located outside by the kitchen had trash inside and was not securely closed with the dumpster lid. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. A staff member did not perform handwashing according to facility protocol; 2. The facility did not implement Legionella (a bacteria that can cause legionnaire's disease [a type of pneumonia]) water management program policy and procedure; and 3. A licensed nurse did not sanitize blood pressure equipment in between use. These failures had the potential to result in cross contamination which could cause illnesses to a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet and portion sizes for lunch on November 7, 2022, and lunch on November 8, 2022, when: 1. Resident 30 was on CCHO (consistent carbohydrate, a diet treatment for diabetes), NAS (no added salt), Renal (a diet treatment for chronic kidney disease or end stage kidney disease) with finger food (food items that are in bite size and can pick up by fingers to consume) did not receive a wheat roll as indicated on the menu; 2. Three residents (Resident 8, 22, and 304) received incorrect portion sizes, when: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed for two of 50 residents reviewed for resident rights (Residents 34 and 43), during dining observation: 1. For Resident 34, the staff member was not positioned according to facility standards; and 2. For Resident 43, the resident was not positioned according to facility standards. These failures had the potential for Resident 34 and 43, to not attain their highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility) for one of three residents reviewed for SNF ABN (Resident 39). This failure had the potential to result in the resident to not be informed about the potential liability for payment in non-covered Medicare Part A services in writing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was updated for one of four residents reviewed for PASARR (Resident 25). Resident 25 had developed a new diagnosis and was provided antipsychotic (a class of psychotropic [drugs that affecta person's mental state]) medication on September 14, 2021. This failure had the potential for the resident to be inapproriately placed in the facility, and not receive the treatment and services to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure for two of 15 residents reviewed for care planning (Residents 25 and 36), when: 1. For Resident 25, the care plan was initiated for wandering and elopement; and 2. For Resident 36, the care plan intervention for Lance Adam's Syndrome (generalized muscle jerks) was implemented. This failure had the potential to result in injury when resident experienced uncontrollable movements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of 50 residents (Resident 17), care and services were provided according to accepted standards of clinical practice when the resident was allowed to self-administer her medications. This failure had the potential to result in unsafe adminstration of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and care were provided in accordance with professional standards of practice, for two of 15 residents residents reviewed for quality of care (Residents 25 and 32) when: 1. For Resident 25, the blood work was completed according to the physician order on September 2022; and 2. For Resident 32, the physician order was followed for administration of Resource 2.0 (a nourishment to increase caloric intake). These failures had the potential for Resident's orders to not be followed resulting in a delay of care and physical well being.

Inspectors wroteBased on interview and record review, the facility failed for one of seven residents reviewed for unnecessary medications (Resident 34) to ensure that the pharmacy recommendation for September 23, 2022, regarding the use of Atarax (hydroxyzine-is used to relieve itching caused by allergic skin reactions) was acted upon promptly. This failure had the potential for Resident 34 to experience the adverse side effect such as sedation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven residents (Resident 25), was assessed by the physician for the use of antipsychotic medication. This failure had the potential to result in unnecessary use of antipsychotic medication for Resident 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the licensed nurse administered medications according to the physician's order when two medications were not administered for one of four residents observed during medication pass (Resident 5). These failures resulted in a medication error rate of 7.69 percent and increased the potential of harm to residents due to medications not being administered as prescribed by the physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of 50 residents (Resident 22), an identified concern regarding missing personal belongings was tracked, reviewed, and followed by the committee. This failure resulted in an unsettled resolution to the identified concern affecting the quality of care, quality of life, and resident safety.