Longwood at Oakmont

In the surveyor’s words

From the most serious findings on record at Longwood at Oakmont, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 20, 2023

  Based on review of facility policies, clinical records, incident reports, facility documents, employee file, employee statements, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (fracture of right fibula-lower leg) for one of three residents reviewed (Resident R1). This was identified as harm for past non-compliance for Resident R1. Findings include: Review of the facility policy Skilled Nursing-Abuse dated 5/11/22 indicated that neglect is the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. […]

• Actual harm, isolatedF689Jan 20, 2023

  Based on review of facility policies, clinical records, incident reports, facility documents, employee file, employee statements, and staff interviews, it was determined that the facility failed to ensure that a resident received adequate supervision and was provided a safe transfer, which resulted in actual physical harm (fracture of right fibula-lower leg) for one of three residents reviewed (Resident R1). This was identified as harm for past non-compliance for Resident R1. Findings include: Review of facility policy Skilled Nursing Adverse Events last reviewed 3/4/22, indicated that adverse events are unexpected occurrences that result in serious injury, or loss of customer satisfaction, the most common events are safety fall events. […]

• Actual harm, isolatedF689Oct 6, 2022

  Based on review of facility policies, clinical records and hospital documents, staff interviews and written statements it was determined that the facility failed to make certain that a resident received adequate supervision and was provided a safe transfer resulting in actual harm when a resident fell during a transfer causing the resident to sustain a right femur bone (longest bone in the body) fracture at the distal end of the bone that was comminuted, displaced and angulated (fracture of the upper leg bone where the break is closer to the knee than the hip, the leg bone is broken in two and pointing at an odd angle) for one of four residents (Resident R1). […]

• No harm, potential for more than minimal, widespreadF812Mar 17, 2023

  Based on a review of facility policy, observations and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition and failed to prepare and serve food in a sanitary manner creating the potential for cross contamination in the kitchenette of the facility. Findings include: Review of the facility policy Cleaning and Sanitizing of work surfaces last reviewed on 11/9/22, indicated that food service employees are responsible for cleaning and sanitizing tasks effectively. A schedule is completed and posted to ensure routine cleaning is completed. Review of the facility policy Food Storage last reviewed on 11/9/22, indicated that food is stored immediately after receipt. […]

• No harm, potential for more than minimal, patternF695Feb 18, 2026

  Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of six residents (Residents R7, R11, R13, and R26).Findings include:Review of facility policy Cleaning, Changing Nasal Cannulas and Masks dated 11/5/25, indicated all residents who are receiving oxygen therapy shall have masks and nasal cannula tubing changed weekly and/or as needed.Review of facility policy CPAP and BiPAP (Continuous Positive Airway Pressure keeps airways open when you sleep and Bilevel Positive Airway Pressure -normalizes breathing by delivering pressurized air) dated 11/5/25, indicated use clean, distilled water only in the humidifier chamber.Review of the… […]