Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Glen Post Acute during CMS and state inspections, most recent first.
The facility did not monitor or record resident room temperatures for three consecutive days, as required by policy. During this period, a resident noticed warmer conditions and reported them to staff, but no temperature checks were performed due to the absence of the maintenance director. This lapse prevented timely identification of potential issues with the air conditioning system.
Surveyors found unsanitary conditions in kitchen and storage areas, including crumbs, debris, and grime under shelves, on equipment, and inside refrigeration units. Food storage containers and a fan had visible debris, and several cutting boards were deeply scored and rough. The Director of Dietary Services and Registered Dietitian confirmed these conditions did not meet facility policies for cleanliness and sanitation.
The facility did not follow its policy requiring two staff to witness the destruction of unused non-controlled medications. The DON confirmed that several medications were disposed of without the required witnesses, which did not comply with the established procedures for medication destruction.
The facility did not ensure proper infection control practices, including failing to promptly remove and discard empty IV antibiotic bags, not posting required Enhanced Barrier Precaution (EBP) signage or providing PPE near a resident's room with an indwelling catheter, and allowing two non-staff transporters to transfer a resident with end stage renal disease without wearing appropriate PPE. These deficiencies were confirmed through direct observation, staff interviews, and record review.
Two residents were affected when the facility failed to ensure that a copy of an executed advance directive was available in the medical record for one resident with aphasia, and did not provide information or education about advance directives to another resident with fluctuating decision-making capacity. These lapses resulted in the residents' wishes regarding medical treatment not being properly documented or communicated to staff.
A resident with acute respiratory failure and heart failure was observed repeatedly turning off her oxygen concentrator, with no staff intervention or monitoring to ensure compliance with prescribed oxygen therapy. Nursing staff were unaware of the resident's oxygen use, and there was no care plan addressing her behavior of disabling the equipment, resulting in a failure to follow physician orders and facility policy for comprehensive care planning.
A resident with diabetes and muscle wasting experienced significant, ongoing weight loss despite previous dietary interventions. The RD, DON, and DS were not informed of the continued decline, and there was no documentation of further assessment or action, contrary to facility policy requiring prompt communication and intervention for notable changes in condition.
A resident with a history of respiratory failure and CHF did not receive oxygen therapy as ordered, with observations showing the oxygen flow rate set higher than prescribed and the concentrator frequently turned off by the resident. Nursing staff failed to consistently check and ensure the correct oxygen flow rate and usage, and documentation was inconsistent with the physician's order and care plan requirements.
The facility failed to complete baseline care plans within 48 hours for two residents and did not provide copies to residents or their representatives during the initial IDT conference. Resident 1, with muscle wasting, and Resident 2, with a history of falling, had incomplete care plans. Additionally, Resident 3, with a fractured hip, did not receive a copy of the care plan. The facility's policy requires completion and distribution of care plans, but this was not adhered to.
A facility failed to send a transfer notice to the LTC Ombudsman for a resident transferred to a hospital for catheter reinsertion. The resident was cognitively intact and capable of making decisions. The DON and SSD acknowledged the oversight, with the SSD unaware of the requirement to notify the Ombudsman for transfers. Facility policy requires sending the notice to the Ombudsman simultaneously with the resident and representative.
The facility failed to maintain a comfortable environment as the temperature in a resident's room and hallway exceeded 81°F. The air conditioning was not functioning properly, and staff were unaware of the issue until a surveyor visit. The Maintenance Director confirmed the system lacked sufficient freon, and the temperature was 83°F, above the facility's policy range of 71-81°F.
The facility failed to store, prepare, and serve food under sanitary conditions by refreezing thawed bacon and not maintaining a thawing log. This had the potential to cause foodborne illnesses for 56 medically vulnerable residents.
The facility failed to ensure dietary staff followed the manufacturer's instructions for testing sanitizing solution, potentially leading to foodborne illness. The Cook dipped the test strip for five seconds instead of the recommended 1-2 seconds, risking inaccurate results and bacterial growth.
The facility failed to ensure that the call light was within reach for a resident with a history of cerebral infarction and left hemiplegia. The resident was observed unable to reach the call light, and a CNA confirmed it should have been within easy reach.
The facility failed to ensure a copy of a resident's Advance Directive was available in the medical record, making it inaccessible to staff and the physician. The resident had severe cognitive impairment and an Advance Directive Acknowledgement, but no documented evidence of the AD was found in the record.
The facility failed to follow up on PASARR Level II evaluations for two residents with mental disorders, despite positive Level 1 screenings indicating the need for further evaluation. The DON confirmed that the required follow-ups were not performed, contrary to the facility's policy.
The facility failed to monitor and report bruising in a resident on anticoagulant therapy, leading to a potential delay in treatment. The resident was observed with a bruise, and staff confirmed that monitoring and physician notification protocols were not followed.
The facility failed to follow the prescribed Fortified NAS Mechanical Soft diet for a resident by not adding the required extra gravy, as observed during lunch tray preparation. This omission was confirmed by the Cook and the FNSD, and it contradicted the facility's policy and the RD's recommendations.
The facility failed to accommodate a resident's food preference for no fish, resulting in the resident being served fish when the kitchen ran out of meatloaf. The Food and Nutrition Service Director confirmed that the resident's preference was documented but not honored.
The facility failed to ensure proper storage of leftover food brought by visitors when the refrigerator temperature was at 44°F. A cup of soup inside the refrigerator was not labeled with a name or date. The Food and Nutrition Service Director confirmed that the food should be labeled and stored at temperatures below 41°F, as per the facility's policy.
The facility failed to offer a newly hired CNA the COVID-19 vaccination and provide education on its benefits and risks. The CNA, hired in March 2024, had not been offered the vaccine or educated on it, despite the facility's policy requiring such actions. This oversight was confirmed by both the DSD and the IP.
The facility failed to protect residents from sexual abuse by another resident, resulting in repeated incidents of inappropriate sexual behavior. Despite being aware of the behavior, the facility did not update the care plan or effectively monitor the resident, leading to multiple incidents of unwanted touching and kissing.
Failure to Monitor and Record Resident Room Temperatures
Penalty
Summary
The facility failed to monitor and record resident room temperatures for three consecutive days in July 2025. Review of the facility's Room and Hallway Temperature Log revealed missing entries for July 4, 5, and 6. The Maintenance Director (MTD) confirmed that temperatures were not checked or logged during these days due to his absence, and no other staff performed the required monitoring. Facility policy requires daily temperature checks, including weekends, to ensure a safe and comfortable environment for residents. During interviews, a resident reported noticing warmer than usual temperatures on one of the days in question and notified staff, but was unsure if any repairs were being made. The facility's policies specify that maintenance personnel are responsible for maintaining the heating and cooling systems and ensuring comfortable and safe temperatures. The failure to monitor and document room temperatures as required prevented the facility from identifying potential issues with the air conditioning system during this period.
Deficient Sanitation and Food Storage Practices in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and food storage areas regarding safe and sanitary food preparation and storage practices. Crumbs, debris, and trash were found under storage shelves in both the storeroom and disaster supply room. Four clear food storage container lids and a kitchen fan had visible white debris and dust buildup. Several canned goods had white residue from a spilled cake mix that had not been cleaned. The walk-in refrigerator and freezer contained dried residue, crumbs, grime, and debris on the floors and surfaces. Additionally, three cutting boards were found with deep indentations and rough surfaces, making them difficult to clean and sanitize. Interviews with the Director of Dietary Services and the Registered Dietitian confirmed that these conditions did not meet the facility's own policies for cleanliness and sanitation. Both staff members acknowledged that the observed debris, grime, and damaged equipment should have been addressed to prevent cross-contamination. The facility's policy required all kitchen areas, utensils, and equipment to be kept clean and staff to maintain cleanliness throughout their work. These deficiencies were observed in areas where food was stored, prepared, and served to 57 residents.
Failure to Properly Witness Medication Disposal
Penalty
Summary
The facility failed to ensure that the disposal of multiple unused non-controlled medications was conducted in accordance with its established policy and procedure. Specifically, on May 20, 2025, the destruction of several non-controlled medications, including carvedilol, potassium chloride ER, metformin, pantoprazole DR, amiodarone, divalproex DR, sertraline, and tamsulosin, was not witnessed by two staff members as required. During an interview and record review, the DON confirmed that the medications should have been destroyed in a designated receptacle with two staff present to witness the process, in line with the facility's policy dated April 2019. The DON acknowledged that failure to follow this procedure could allow for medication diversion.
Failure to Implement Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. Two empty antibiotic IV bags, labeled with a previous date, were observed hanging on an IV pole instead of being promptly removed and discarded after use. Both a licensed vocational nurse and the infection preventionist confirmed that these items should have been removed immediately to prevent potential cross-contamination and the accumulation of bacteria. Additionally, there was no Enhanced Barrier Precaution (EBP) signage or available personal protective equipment (PPE) near the room of a resident with paraplegia and an indwelling catheter, despite the care plan requiring such measures. Staff interviews confirmed that the absence of signage and PPE could result in staff and non-staff being unaware of the necessary precautions before entering the room. In another instance, two non-staff transporters entered the room of a resident with end stage renal disease, who was on EBP due to an indwelling catheter, without wearing the required PPE while attempting to transfer the resident. The infection preventionist stated that proper PPE should have been worn during this high-contact activity, as indicated by the resident's care plan and facility policy. These lapses in infection control practices were directly observed and confirmed through staff interviews and record reviews.
Failure to Ensure Advance Directives Are Documented and Residents Are Educated
Penalty
Summary
The facility failed to ensure that residents' rights regarding advance directives (AD) were honored for two of six residents reviewed. For one resident with aphasia following a non-traumatic intracerebral hemorrhage, although an advance directive was executed upon admission, a copy of the AD was not available in the resident's record. The Social Services Director (SSD) confirmed that the AD should have been accessible in the record for nurses and physicians to reference, especially in situations where the resident is unconscious. The absence of the AD in the record could result in care being provided that does not align with the resident's wishes. For another resident with fluctuating capacity to understand and make decisions, there was no documentation that the resident or their representative had been provided with information or education regarding the formulation of an AD. The resident was unaware of what an AD was, and the SSD acknowledged that neither education nor a review for AD had been conducted for this resident. The facility's policy requires staff to inquire about the existence of an AD and to offer assistance and document the resident's decision, but this process was not followed.
Failure to Ensure Consistent Oxygen Therapy per Care Plan
Penalty
Summary
The facility failed to ensure that a resident with acute respiratory failure with hypoxia and heart failure was consistently receiving oxygen therapy as outlined in her care plan. Observations revealed that the resident repeatedly turned off her oxygen concentrator in response to alarms, and staff did not intervene or monitor her oxygen use during these incidents. On multiple occasions, the resident was found with the oxygen concentrator turned off and the nasal cannula not in place, despite physician orders for continuous oxygen therapy and a care plan specifying the need for compliance with oxygen use and regular monitoring. Interviews with nursing staff indicated a lack of awareness regarding the resident's current oxygen use and rate, and staff acknowledged that the resident had a pattern of turning the machine on and off independently. The Director of Nursing confirmed that there was no care plan addressing the resident's behavior of disabling the oxygen concentrator and that nurses were not consistently checking the oxygen equipment or assessing the resident each shift as required. Facility policy required comprehensive, person-centered care plans that address identified problems and risk factors, but this was not implemented for the resident's oxygen therapy needs.
Failure to Address and Communicate Significant Resident Weight Loss
Penalty
Summary
The facility failed to ensure that adequate nutritional care and services were provided to a resident with a history of diabetes mellitus and muscle wasting. The resident experienced significant weight loss over a short period, losing 4 pounds in one week and an additional 5 pounds in the following weeks. Although the Registered Dietitian (RD) had previously recommended a fortified diet and the physician had agreed to the change, there was no documentation or evidence that the resident's continued weight loss in May was addressed. The care plans included monitoring for weight loss and malnutrition, but there was no indication in the progress, dietary, or nutritional notes that the ongoing weight loss was discussed or acted upon after the initial intervention. Interviews with facility staff revealed a breakdown in communication and monitoring. The RD, Director of Nursing (DON), and Dietary Supervisor (DS) were not made aware of the resident's continued weight loss in May, despite facility policies requiring notification and intervention for significant changes in condition. The DON acknowledged that a change of condition should have been reported and that the nursing staff failed to communicate the weight loss to the appropriate team members. Facility policies emphasized the importance of multidisciplinary monitoring and timely intervention for undesirable weight loss, but these procedures were not followed in this case.
Failure to Provide Physician-Ordered Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure with hypoxia and congestive heart failure did not receive respiratory care in accordance with the physician's order. The resident was observed using oxygen at a flow rate of four liters per minute (LPM) via nasal cannula, despite the physician's order specifying two LPM continuously and as needed. The resident was also observed turning off the oxygen concentrator due to frequent alarms and was unsure of the correct oxygen flow rate. On a subsequent observation, the oxygen concentrator was found turned off and the nasal cannula was not in use, with the resident stating she had turned it off due to noise. Nursing staff confirmed that the resident had a habit of turning the machine on and off and resetting it herself, and acknowledged that the oxygen flow rate was set incorrectly at four LPM instead of the ordered two LPM. Staff also indicated that it was their responsibility to check the oxygen flow rate and ensure compliance with the physician's order, but this was not consistently done. Record review showed inconsistencies in the documentation of oxygen administration, with the physician's order ambiguously stating both continuous and as-needed use, and the care plan requiring monitoring of oxygen saturation and administration at a specified rate. The facility's policy required verification of physician orders, review of care plans, and documentation of oxygen flow rate, route, and rationale, as well as assessment of oxygen use each shift. However, these procedures were not followed, resulting in the resident not receiving oxygen therapy as ordered and staff failing to ensure the correct oxygen flow rate and usage.
Failure to Complete and Distribute Baseline Care Plans
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for two residents. Resident 1 was admitted with a diagnosis of muscle wasting and moderate cognitive impairment, but the rehabilitation and dietary services did not complete their portions of the baseline care plan until five days after admission. Similarly, Resident 2, admitted with a history of falling, had incomplete baseline care plans from the rehabilitation and social services departments, which were not finalized until three days after admission. Additionally, the facility did not provide copies of the baseline care plans to the residents or their representatives during the initial interdisciplinary team (IDT) conference. For Resident 1, there was no documentation that a copy of the baseline care plan was provided or offered during the IDT meeting. The same issue was observed for Resident 3, who was admitted with a fractured hip and moderate cognitive impairment. Interviews with various department heads, including the Activities Director, Rehabilitation Director, Dietary Supervisor, and Social Services Director, confirmed that copies of the baseline care plans were not provided to residents or their representatives. The facility's policy, revised in March 2022, mandates that baseline care plans be completed within 48 hours of admission and that a written summary be provided to the resident or their representative. However, the Director of Nursing confirmed that this practice was not being followed, as copies of the baseline care plans were not being given or offered during the initial IDT conference.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the transfer/discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman for a resident who was transferred to a hospital. The resident, who was cognitively intact and capable of making decisions, was admitted to the facility with diagnoses including muscle wasting and atrophy. The transfer occurred for the reinsertion of a dislodged suprapubic catheter, but there was no documented evidence that the transfer notice was sent to the LTC Ombudsman. During interviews, both the Director of Nursing and the Social Service Director acknowledged the oversight. The Director of Nursing stated that the process involves giving the notice to the resident upon transfer or discharge and sending it to the LTC Ombudsman within 30 days. However, the Social Service Director admitted to not sending the notice, citing a lack of awareness that it was required for transfers. The facility's policy, dated March 2021, mandates that a copy of the notice be sent to the Ombudsman at the same time it is provided to the resident and representative.
Facility Fails to Maintain Comfortable Temperature
Penalty
Summary
The facility failed to maintain a comfortable environment for its residents when the temperature in one of the resident's rooms and the facility hallway exceeded 81 degrees Fahrenheit. This issue was identified during an unannounced visit on July 9, 2024, following a complaint about the physical environment. The Resident Representative reported that the air conditioning had not been functioning since July 6, 2024, and that the facility was uncomfortably hot, causing a resident to wake up soaked in sweat. The Maintenance Director and Maintenance Assistant were unaware of the issue until the day of the visit, indicating a lack of communication and reporting from the staff. During the visit, the Maintenance Director confirmed that the air conditioning system was lacking sufficient freon, which is essential for the cooling process, and that the temperature in the hallway and Resident A's room was 83 degrees Fahrenheit. The facility's policy states that a comfortable and safe temperature should range from 71 to 81 degrees Fahrenheit. Interviews with the Certified Nursing Assistant and the Director of Nursing confirmed that the temperature was above the comfortable range, and the staff acknowledged the importance of maintaining a comfortable environment for the residents.
Improper Food Storage and Lack of Thawing Log
Penalty
Summary
The facility failed to ensure food items were stored, prepared, and served under sanitary conditions. Specifically, fifteen pounds of bacon were thawed and then refrozen, which is against proper food safety protocols. During an initial tour of the kitchen, it was observed that four one-gallon plastic bags containing bacon were not frozen solid. The Food and Nutrition Service Director (FNSD) confirmed that the bacon should have been frozen solid when stored in the freezer. The FNSD admitted that the cook had thawed the bacon and then refrozen the remaining portion, which could lead to bacterial growth and potential foodborne illnesses. The U.S. FDA Food Code 2022 indicates that improper thawing and refreezing of food can preserve harmful bacteria and toxins, posing a risk to the residents' health. Additionally, the facility did not maintain a thawing log as required by their policy and procedure. The cook confirmed that there was no thawing log available to track the thawing process of meat, which is essential to ensure that food stays within a safe temperature range. The facility's policy, dated 2018, mandates that thawed food must be labeled and dated with a pull-out date and use-by date, and should not exceed three days past the use-by date. The lack of a thawing log and improper handling of thawed bacon had the potential to result in foodborne illnesses for 56 medically vulnerable residents.
Improper Sanitizing Solution Testing
Penalty
Summary
The facility failed to ensure the dietary staff performed testing of the sanitizing solution according to the manufacturer's instructions. During an observation, the Cook was seen dipping the test strip into the sanitizing solution for five seconds instead of the recommended 1-2 seconds. The Cook acknowledged that this deviation from the manufacturer's instructions could result in inaccurate test results, potentially promoting the growth of bacteria that could cause foodborne illness. The facility's policy, dated 2018, also emphasized the importance of following the manufacturer's instructions for testing QUAT concentration to avoid chemical contamination of food.
Call Light Not Within Reach for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, Resident 54. On April 9, 2024, at 8:01 a.m., Resident 54 was observed lying in bed with the call light hanging between the floor and the bed, out of his reach. Resident 54 confirmed that he could not call for assistance. During a concurrent interview and observation at 8:33 a.m., CNA 1 acknowledged that the call light was not within reach and stated that it should be placed within easy reach of the resident. Resident 54's medical history includes a cerebral infarction and left hemiplegia, and his cognitive status was assessed as intact. The facility's policy, dated October 2010, mandates that the call light should be within easy reach when the resident is in bed or confined to a chair.
Failure to Ensure Advance Directive Availability
Penalty
Summary
The facility failed to ensure a copy of the Advance Directive (AD) for Resident 49 was available in the resident's medical record, making it inaccessible to staff and the physician. Resident 49, who was admitted to the facility on an unspecified date, had severe cognitive impairment as indicated by the Minimum Data Set dated March 14, 2024. Despite having an Advance Directive Acknowledgement dated January 22, 2024, there was no documented evidence of the AD in the resident's medical record. During a concurrent interview and record review on April 10, 2024, the Social Service Director (SSD) confirmed that Resident 49's AD was not available in the resident's record. The SSD acknowledged that the AD should have been accessible to staff and the physician. The facility's policy, dated December 2016, mandates that information about an advance directive should be prominently displayed in the medical record, which was not adhered to in this case.
Failure to Follow Up on PASARR Level II Evaluations
Penalty
Summary
The facility failed to follow up on Level II Preadmission Screening and Resident Review (PASARR) evaluations for two residents, which is a federal requirement to ensure individuals with mental disorders or intellectual disabilities are appropriately placed in nursing homes. Resident 42, admitted with major depressive disorder and mild neurocognitive disorder, had a positive PASARR Level 1 screening indicating the need for a Level II evaluation. However, there was no documented evidence that the required Level II evaluation was conducted. The Director of Nursing (DON) confirmed that the follow-up was not performed as required. Similarly, Resident 44, admitted with schizoaffective disorder, also had a positive PASARR Level 1 screening indicating the need for a Level II evaluation. Again, there was no documented evidence that this follow-up was conducted. The DON acknowledged that the facility and nursing staff should have ensured the PASARR Level II evaluations were completed for both residents. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders and referred for a Level II evaluation if the Level 1 screening is positive, but this procedure was not followed in these cases.
Failure to Monitor and Report Bruising in Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that Resident 10, who was on anticoagulant therapy due to a history of cerebrovascular accident (CVA), was monitored for signs and symptoms of bleeding or bruising, and that the physician was notified of any such findings. On April 9, 2024, Resident 10 was observed with a bruise on her right upper arm, which she could not recall how she got. Despite the care plan indicating the need for monitoring and reporting any bruising or bleeding, there was no documentation of such monitoring for the past two weeks. Certified Nurse Assistant (CNA) 1 was unaware of the bruise and had not reported it to the licensed nurse, as required by protocol. Licensed Vocational Nurse (LVN) 1 confirmed that CNAs should report any skin changes to the licensed nurse, who should then assess the issue. LVN 2 also confirmed that the resident should have been monitored every shift and the physician notified of any bruising or bleeding. During a concurrent interview and record review with LVN 2, it was confirmed that Resident 10 had not been monitored for signs and symptoms of bleeding or bruising for the past two weeks. LVN 2 observed the bruise on Resident 10's right upper arm and acknowledged that the resident should have been monitored and the physician notified. This lack of monitoring and communication had the potential for delayed treatment and management of the resident's condition.
Failure to Follow Fortified Diet Requirements
Penalty
Summary
The facility failed to follow the prescribed menu for a resident on a Fortified NAS Mechanical Soft diet with chopped meat. On April 10, 2024, during lunch tray preparation, the Cook did not add the required extra scoop of gravy to the resident's meal, which is necessary to fortify the diet. This was observed and confirmed during an interview with the Cook, who acknowledged the omission despite the meal tray card indicating the need for fortification. The Food and Nutrition Services Director (FNSD) also confirmed that extra gravy should be added to fortify the diet. A review of the resident's records showed a significant weight change and a recommendation from the Registered Dietician (RD) to fortify the current diet. The facility's policy on food fortification, dated 2018, specifies that extra gravy and sauces should be added to increase calorie and protein intake. The failure to follow this policy and the resident's specific dietary requirements had the potential to not meet the resident's nutritional needs.
Failure to Accommodate Resident's Food Preference
Penalty
Summary
The facility failed to accommodate Resident 159's food preference for no fish, resulting in the resident being served fish. This incident occurred when the kitchen ran out of meatloaf during meal service and substituted it with chicken and fish. The Cook confirmed that seven residents, including Resident 159, were not served meatloaf and were given fish or chicken instead. Resident 159, who has a documented dislike for fish, expressed dissatisfaction with being served fish for lunch. The Food and Nutrition Service Director (FNSD) reviewed Resident 159's meal service card and confirmed that the resident's preference for no fish was clearly indicated. The facility's policy on food preferences, dated 2018, states that resident food preferences should be adhered to within reason and that substitutes for disliked foods should be provided from the appropriate food group. The failure to honor Resident 159's food preference was a deviation from this policy, as acknowledged by the FNSD.
Improper Storage of Leftover Food
Penalty
Summary
The facility failed to ensure proper storage of leftover food brought by visitors or family members when the temperature of the refrigerator at the nurses' station was at 44°F. During an observation and interview with the Food and Nutrition Service Director (FNSD), it was noted that a cup of soup inside the refrigerator was not labeled with a name or date. The FNSD confirmed that the food should be labeled with the resident's name and a use-by date, and that the refrigerator temperature should be below 41°F. The facility's policy, dated October 2017, indicated that perishable foods must be stored at temperatures below 41°F and labeled appropriately. This failure had the potential to expose residents to foodborne illness.
Failure to Offer COVID-19 Vaccination and Education to New Staff
Penalty
Summary
The facility failed to ensure that a newly hired Certified Nursing Assistant (CNA) was offered the COVID-19 vaccination and provided with education regarding the benefits and risks of the vaccine. During an interview and review of the CNA's Employee Onboarding File, it was revealed that the CNA, who was hired on March 19, 2024, had received their last COVID-19 vaccination on February 10, 2022. The Director of Staff Development (DSD) acknowledged that the CNA should have been offered the vaccine upon hire. Additionally, the Infection Preventionist (IP) confirmed that the CNA was neither offered the COVID-19 vaccine nor educated on COVID-19 immunization upon hire, despite the IP being responsible for these tasks. The facility's policy, dated May 2017, mandates that staff are educated about the benefits and risks of the COVID-19 vaccine and are offered the vaccination. The policy also requires that each staff member is provided with education regarding the benefits and risks of the vaccine, especially if multiple doses are required. The IP emphasized the importance of offering vaccinations and educating staff to protect vulnerable residents and prevent the spread of infections. This oversight had the potential to leave staff without necessary guidance and information regarding the COVID-19 vaccine, thereby compromising the safety of both staff and residents.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse by another resident, resulting in repeated incidents of inappropriate sexual behavior. Resident 1, who had a diagnosis of major depressive disorder, exhibited inappropriate sexual behavior towards multiple residents, including kissing and touching without consent. Despite these incidents, the facility did not reevaluate or update the interventions in Resident 1's care plan to effectively address and prevent further inappropriate behavior. The report details several incidents involving Resident 1, including kissing a confused resident, attempting to touch another resident, and inappropriately touching a resident in a wheelchair. Additionally, Resident 1 was observed masturbating in a restroom and smearing semen on walls and doorknobs. Despite these behaviors, the facility's monitoring of Resident 1 was inconsistent, with gaps in documentation and ineffective interventions. Interviews with staff revealed that they were aware of Resident 1's inappropriate behavior but did not take sufficient action to prevent further incidents. The care plan for Resident 1 was not updated to reflect appropriate interventions, and the interdisciplinary team failed to reevaluate the effectiveness of the existing measures. The facility's policies on resident-to-resident altercations and abuse prevention were not adequately followed, leading to repeated incidents of sexual abuse by Resident 1.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cherry Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Springs Care Center | 2.7 mi | ★★★★★ | 23 | 0 |
| Vista Real Post Acute | 3.7 mi | ★★★★★ | 2 | 0 |
| Sundance Creek Post Acute | 3.9 mi | ★★★★★ | 14 | 0 |
| Sunrise Post Acute | 4.7 mi | ★★★★★ | 30 | 0 |
| Yucaipa Hills Post Acute | 4.8 mi | ★★★★★ | 9 | 0 |
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