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Inspection visit

Health inspection

OAK GLEN POST ACUTECMS #5554921 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

555492 08/15/2025 Oak Glen Post Acute 9246 Avenida Miravilla Cherry Valley, CA 92223
F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based 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. Findings:A review of the facility documents titled, Room and Hallway Temperature Log, Month of July 2025, indicated missing temperature entries on the following dates:- July 4, 2025- July 5, 2025; and- July 6, 2025On July 15, 2025, at 10:10 a.m., an interview was conducted with the Maintenance Director (MTD). The MTD stated the compressor for the facility's air conditioning (AC) system broke down on July 11, 2025. The MTD stated this was the only day the AC unit had malfunctioned. The MTD stated he immediately placed a call with their vendor who helped with their AC maintenance, and they came to check the units that same day and provided an estimate of cost for the replacement of the compressors. The MTD stated, meanwhile, he placed fans in each resident room and an industrial cooling unit in the hallway.On July 15, 2025, at 10:29 a.m., an interview was conducted with Resident 3. Resident 3 stated on July 5, 2025, she noticed the building temperature felt warmer than usual and suspected the AC unit had broken down. Resident 3 further stated she notified staff but wasn't sure if repairs were being made.On July 15, 2025, at 3:34 p.m., a concurrent interview and record review of the facility's resident room temperature logs was conducted with the Maintenance Director (MTD). The MTD stated the facility's protocol was to monitor resident room temperatures daily, including on weekends. The MTD stated he did not work from July 4, 2025, to July 6, 2025, and in his absence, the temperatures were not checked on those days. The MTD stated the room temperatures should have been checked to ensure they were not too high as elevated temperatures could cause discomfort and place residents at risk of unsafe heat related conditions.On July 15, 2025, at 4:45 p.m., a concurrent interview and record review of the facility's resident room temperature logs was conducted with the Administrator (ADM). The ADM stated to ensure resident safety, MTD staff were responsible for monitoring and recording resident room temperatures daily, including weekends. The ADM further stated, MTD staff should have checked and logged the temperatures on July 4 to 6, 2025, to ensure the AC was functioning properly and that the room temperatures were not elevated, to prevent residents from experiencing discomfort or conditions such as heat stroke or dehydration. A review of facility's policy and procedure titled, Homelike Environment, dated 2001, indicated, .residents are provided with a safe, clean, comfortable and homelike environment and.the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.these characteristics include.comfortable and safe temperatures (71 -81 F (Fahrenheit [temperature scale]).A review of facility's policy and procedure titled, Maintenance Service, dated 2001, indicated, .maintenance service shall be provided to all areas of the building, grounds, and equipment .functions of the maintenance personnel include, but are not limited to .maintaining the heat/cooling Page 1 of 2 555492 555492 08/15/2025 Oak Glen Post Acute 9246 Avenida Miravilla Cherry Valley, CA 92223
F 0921 system . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555492 Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0921GeneralS&S Dpotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

FAQ · About this visit

Common questions about this visit

What happened during the August 15, 2025 survey of OAK GLEN POST ACUTE?

This was a inspection survey of OAK GLEN POST ACUTE on August 15, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at OAK GLEN POST ACUTE on August 15, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.