Oak Glen Post Acute

In the surveyor’s words

From the most serious findings on record at Oak Glen Post Acute, in the surveyor’s own words.

• Actual harm, patternF600Mar 20, 2024

  Based 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). Findings: On January 10, 2024, at 10:50 a.m., an unannounced visit was conducted to investigate an allegation of sexual abuse. […]

• Actual harm, isolatedF684Mar 17, 2021

  Based on interview and record review the facility failed to ensure that one of seven sampled residents (Resident A) received necessary treatment and care in accordance with professional standards of practice. This failure occurred when the facility: 1. Did not ensure Resident A received the physician ordered insulin (medication that lowers the level of glucose [sugar] in the blood) after admission to the facility, and 2. Did not provide Resident A with necessary blood sugar monitoring. […]

• No harm, potential for more than minimal, widespreadF812May 22, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 12, 2024

  Based 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. Findings: 1. On April 8, 2024 at 9:08 a.m., during initial tour of the kitchen with the Food and Nutrition Service Director (FNSD), inside the freezer, four-one-gallon plastic bags containing bacon were observed not frozen solid. […]

• No harm, potential for more than minimal, widespreadF812Nov 10, 2022

  Based 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. Findings: 1. […]