Oak Glen Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Oak Glen Healthcare and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 22, 2025

  Based on observation and staff interview, it was determined that the facility failed to store and serve food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and two of three open nursing units (Memory Care and Evergreen). Findings include: An observation in the facility's main kitchen on August 19, 2025, with Employee 1, dining director, revealed the following: Tile flooring extending through the corridor to enter the kitchen food preparation and food storage areas and extending in front of the dishwashing area was significantly dull, blackened, and contained dried spills, dirt, and debris, which was also observed in the corners of the doorway entrance to the area. […]

• No harm, potential for more than minimal, widespreadF812Oct 21, 2022

  Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition in the main kitchen. Findings include: Initial tour of the facility's main kitchen on October 18, 2022, at 9:10 AM with Employee 3, Director of Dining, revealed the following: A build-up of crumbs and debris in the drawers of a stainless-steel cabinet located on a perimeter wall. A lidded garbage can with brownish-colored stains covering the exterior. A stainless-steel cabinet on a perimeter wall and the top-shelf had a film and build-up of dust and debris. A catering rack with significant build-up of dust on the shelves. There was a black bowl with a build-up of large white flakes and debris in the bottom. […]

• No harm, potential for more than minimal, patternF842Feb 19, 2026

  Based on observations and staff interviews it was determined that the facility failed to keep confidential all information in a resident's medical record for three of eight residents reviewed (Residents 3, 5, and 8). Findings include: A review of the facility's policy titled, HIPAA Privacy and Security Policy, dated March 20, 2025, revealed that the facility, is committed to safeguarding the privacy and security of all Protected Health Information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA), including the Privacy Rule, Security Rule, and Breach Notification Rule. […]

• No harm, potential for more than minimal, patternF585Aug 22, 2025

  Based on a review of select facility policies and procedures, the facility's grievance documentation, observation, and resident and staff interview, it was determined that the facility failed to implement effective corrective action in response to a resident's grievance related to staff call bell response for seven of seven residents reviewed for call bell response concerns (Residents 20, 108, 111, 48, 93, 107, and 3).Findings include: Review of the facility policy entitled, Call Light Policy, effective March 20, 2025, revealed that the call system will be monitored regularly to ensure it is functioning properly. The call light must be kept accessible to the resident at all times. Any malfunctioning call lights must be reported to maintenance or the supervisor immediately. […]

• No harm, potential for more than minimal, patternF880Aug 22, 2025

  Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for two of two residents reviewed for antibiotic use (Residents 107 and 111), for three of three residents reviewed for transmission based precautions (Residents 3, 48, and 51), and for the facility's water management program.Findings include: The facility policy entitled, Contact Precautions, effective March 20, 2025, indicated that the purpose of the policy is to use contact precautions for residents known or suspected of having infectious diseases or epidemiologically significant pathogens transmitted by direct resident contact or by contact with… […]