Oakmont Manor

In the surveyor’s words

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

• Actual harm, isolatedF656Dec 7, 2021

  Based on interview, record review, and review of the facility's competency check lists titled, Using the Care Plan and Care Plan Goals and Objectives, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of four (4) sampled residents (Resident #1). The facility assessed and care planned Resident #1 for the extensive assistance of two (2) staff and the use of a mechanical lift for transferring. However, on 07/14/2021, State Registered Nurse Aide (SRNA) #5 transferred Resident #1 using the stand pivot method by herself. During the transfer, Resident #1 sustained a tibia/fibula fracture (a fracture in the lower leg). […]

• Actual harm, isolatedF689Dec 7, 2021

  Based on interview, record review, and review of the facility's competency, Total Mechanical Lift Competency Checklist, undated, it was determined the facility failed to ensure each resident received adequate assistive devices to prevent an accident with injury for one (1) of four (4) sampled residents (Resident #1). The facility's care plan for Resident #1 required the extensive assistance of two (2) staff and the use of a mechanical lift for transferring. However, on 07/14/2021, State Registered Nurse Aide (SRNA) #5 transferred Resident #1 using the stand pivot method by herself. During the transfer, Resident #1's legs became tangled. Resident #1 sustained a tibia/fibula fracture (a fracture in the lower leg). […]

• No harm, potential for more than minimal, widespreadF814Apr 22, 2026

  Based on observation and interview, the facility failed to dispose of refuse in a sanitary manner for 2 of 2 dumpsters observed. This deficient practice had the potential to affect all residents who resided in the facility.The findings include:During an interview on 04/22/2026 at 3:20 PM, the Administrator stated the facility did not have a policy regarding dumpsters.Observation of the facility's dumpsters with the Dietary Manager on 04/20/2026 at 9:55 AM revealed the dumpsters were approximately 100 feet from the facility. Two dumpsters with lids and sliding side doors sat adjacent to each other, surrounded by a concrete brick wall that wrapped around them but did not enclose them. Facing the dumpsters, the left dumpster's right-side door was fully opened. […]

• No harm, potential for more than minimal, patternF812May 2, 2025

  Based on observation, interview, and review of a food safety article, the facility failed to serve food in a sanitary manner as determined by observation of the lunch service on 04/29/2025 and 04/30/2025 when the Dietary staff touched the clear plastic square bowls inside the rims with bare fingers as they turned the bowls over for service. This had the potential to affect all 84 current residents. The findings include: Review of the State Safe Food handling article Server Tips, Hands Off, dated 2025, https://www.statefoodsafety.com/Resources/Resources/server-tip-hands-off#:~:text=More%20importantly%20than%20the%20money,will%20be%20used%20by%20guests, revealed bare hand contact on dishes and utensils was an issue because bare hands spread germs. […]

• No harm, potential for more than minimal, patternF880May 2, 2025

  Based on observation, interview, and review of the facility's policies, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observation on 04/29/2025 revealed Dietary Aide 1 coughed multiple times over the residents' trays on the lunch tray line for the D Unit cart. Dietary Aide 1 coughed into her elbow. However, she did not step back from the tray line, sanitize, or wash her hands. […]