Oakmont Guest Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 24, 2023

  Based on observations, interviews and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #2) of ten residents reviewed for neglect. The facility failed to ensure Resident #2 did not elope from the facility. The facility staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. The resident was located around 6:00 pm 12 miles away from the facility after police became involved and a Silver Alert had been issued. An Immediate Jeopardy was identified on 08/22/23. The IJ Template was provided to the facility on [DATE] at 5:03 PM. […]

• Immediate jeopardy, patternF607Aug 24, 2023

  Based on observations, interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (Resident #2) of ten residents reviewed for neglect policies. The facility failed to ensure their abuse and neglect policy was implemented for Resident #1 when he eloped from the facility. The facility staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. The resident was located around 6:00 pm 12 miles away from the facility after police became involved and a Silver Alert had been issued. An Immediate Jeopardy was identified on 08/22/23. The IJ Template was provided to the facility on [DATE] at 5:03 PM. […]

• Immediate jeopardy, patternF689Aug 24, 2023

  Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for two (Resident #2 and #4) of four residents reviewed for accidents and supervision. 1. The facility staff DA M allowed Resident #2 to leave behind her without ensuring he was not a resident. 2. The facility failed to ensure Resident #2 did not elope from the facility and staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. 3. The facility staff including MA R, LVN P, LVN Q and CNA B and CNA X failed to check on Resident #2 on the 2-10PM, 10PM-6AM, AND 6AM-2PM shifts from 08/19/23 through 08/20/23 to ensure he was present in the facility. […]

• Immediate jeopardy, isolatedF695Oct 31, 2025

  Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 resident (Residents #1) of 7 residents reviewed for respiratory care. -The facility failed to ensure that Residents #1, who required continuous oxygen therapy, received adequate oxygen when his portable oxygen tank ran out of oxygen while the resident was in the community at an appointment on 10/29/2025. Resident #1 was transported to the local hospital and diagnosed with acute hypoxia (low levels of oxygen) The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 10/29/25 and ended on 10/30/25. […]

• Actual harm, isolatedF689Dec 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure that the residents are free from accidents and hazards for one (Resident #1) of two residents reviewed for mechanical lift transfers. The facility failed to safely transfer Resident #1 and prevent injury during the use of the mechanical Hoyer lift, resulting in a laceration on the forehead on 12/16/23 and back pain on 11/20/23. This failure could place residents at risk for accidents that could lead to injuries such as bruising, skin tears and fractures. Findings included: Record review of Resident #1's MDS assessment dated , 10/11/223, revealed the resident was a [AGE] year-old male, who was initially admitted to the facility on [DATE] and readmitted on [DATE]. […]