Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakmont Guest Care Center during CMS and state inspections, most recent first.
Kitchen sanitation and dishwasher temperature deficiencies were identified when the microwave, toaster, steamer, floors, dry ingredient containers, and food prep table were observed with food residue, stains, dust, debris, and stagnant water buildup. The mechanical dishwasher was also found to run at about 97 degrees F instead of the required 120 degrees F, despite staff being expected to monitor and log temps and sanitizer levels. The Dietary Mgr stated kitchen staff were responsible for daily cleaning and sanitation, and the ADM stated staff were expected to follow policy and procedures.
A facility failed to accurately document and account for controlled substances for two residents receiving narcotic pain medications. For one resident, the MAR and narcotic log did not match the pill count for hydrocodone-acetaminophen; for another resident, oxycodone was signed out on the narcotic log but not documented on the MAR. An LPN stated she gave the medications but forgot to complete the required documentation, and the DON said staff were expected to document narcotics on the MAR and narcotic log when administered.
Missing physician order for droplet precautions: A resident returned from the hospital with rhinovirus and was placed on droplet precautions, with the care plan and progress notes reflecting isolation and a sign posted outside the room. However, the chart did not contain a physician order for droplet isolation, and staff, including the IP and DON, were unsure about the timeframe and responsibility for obtaining the order.
A resident dependent on a G-tube for nutrition, with orders for continuous enteral feeding at a set rate and scheduled downtime, did not receive ordered tube feeding when an LVN restarted the feeding pump after downtime but forgot to reconnect the G-tube, causing formula to run onto the floor instead of into the resident. The resident’s responsible party discovered the disconnected, clamped tube and formula on the floor, later confirmed by a CNA and the surveyor. Staff interviews established that the nurse had turned the pump back on without reconnecting the tube, and that facility practice and policy required proper connection and verification of the enteral feeding setup to ensure delivery of prescribed nutrition and hydration.
A resident with chronic respiratory conditions was transported to a medical appointment with only one portable oxygen tank, which became depleted during an extended outing. The resident experienced acute hypoxia and required emergency intervention after running out of oxygen on the return trip. Staff had not implemented procedures to provide an extra oxygen tank for residents on continuous oxygen therapy during off-site appointments.
A resident with severe cognitive impairment and a terminal prognosis did not receive appropriate foot care, specifically toenail trimming, despite being dependent on staff for personal hygiene. The resident expressed discomfort due to long toenails, but staff failed to arrange podiatry care, and the care plan did not address nail care. The facility's foot care policy was not effectively implemented, leading to this deficiency.
A facility failed to develop a comprehensive care plan for a resident, omitting necessary details about activities of daily living (ADLs) despite the resident's severe cognitive impairment and total dependence on staff. The resident expressed concerns about long toenails, which staff did not address, citing the need for a podiatrist who had not seen her as scheduled. Interviews with staff revealed that the omission of ADLs in the care plan was an oversight, contrary to the facility's policy on providing person-centered care.
The facility's kitchen failed to meet food safety standards, with issues including improper hair restraint by a dietary staff member and inadequate food storage practices. Observations revealed unsecured, unlabeled, and undated food items in the dry storage area, walk-in cooler, and freezer. The walk-in cooler's temperature was above the safe limit, lacking an internal thermometer. These deficiencies could lead to food contamination and illness among residents.
A facility failed to provide written notification to a resident, her representative, and the Ombudsman regarding her transfer and discharge to a hospital for behavioral reasons. The resident, with moderate cognitive impairment and other health issues, was transferred due to escalating mental health concerns. The facility did not document the notification in writing, and the resident's POA was only informed verbally. The administrator was unaware of the requirement to notify the Ombudsman in writing for such discharges.
The facility failed to provide privacy curtains in 11 rooms, compromising resident privacy during care. A resident with severe cognitive impairment was exposed when the door opened slightly during a skin assessment, and there was no privacy curtain. Staff were unaware of the issue, and the facility lacked a specific policy on privacy curtains.
A housekeeper in an LTC facility was observed picking popcorn off the floor and placing it back into a resident's bag, which was later consumed by the resident. The resident, an elderly male with dementia, was unable to recall the event. The incident was reported by the resident's family after reviewing video footage, leading to the housekeeper's termination.
Kitchen sanitation and dishwasher temperature deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in its only kitchen. During observation on 06/08/26, the inside of the microwave had food stains and residue, the toaster had food residue on the inside and food stains and rust on the outside, and the food steamer had a metal pan underneath with stagnant water, buildup, and white floating substances. The kitchen floors had excessive dust and debris, three large containers holding dry food ingredients had stains and old sticky food residue, and the food preparation table had food stains and debris. The dishwasher was also observed to be operating below the expected wash temperature. On 06/08/26, the wash cycle reached only about 97 degrees Fahrenheit by digital stick thermometer and by the machine thermometer, although the chemical sanitizing solution concentration was between 50-100 ppm. The Dietary Manager stated he was unaware the temperature was not reaching above 97 degrees Fahrenheit and said the staff would switch to manual dishwashing in a 3-compartment sink where dishes could be rinsed, washed, and sanitized. Later observation on 06/08/26 showed kitchen staff using the 3-compartment sinks with water maintained above 110 degrees Fahrenheit for washing and rinsing and an appropriate chemical concentration in the sanitizing compartment. On 06/09/26, the mechanical dishwasher was observed fixed and reaching 120 degrees Fahrenheit. Record review showed an in-service dated 03/18/26 stating kitchen staff were educated on completing temperature logs for the freezer, refrigerator, dishwasher, food temperatures, and department cleanliness. The Dietary Manager stated he had worked at the facility since November 2024, that all kitchen staff were responsible for keeping the kitchen clean and sanitized daily, and that he was responsible for ensuring cleaning tasks were completed. He stated he assigned tasks to kitchen staff, that appliances and preparation tables should be cleaned after each use, floors after each meal service, dry ingredient containers when emptied and before refilling, and the pan under the steamer daily and as needed. He also stated dishwashing staff were expected to test and log dishwasher temperature and chemical concentration daily. The Administrator stated the expectation was for kitchen staff to follow policy and procedures to keep the kitchen clean and sanitized, and for the Dietary Manager to ensure that it was being done.
Inaccurate Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate documentation and accountability for controlled substances on the Hall 700/Hall 800 nurses’ medication cart. During observation and record review, the narcotic log for Resident #24’s hydrocodone-acetaminophen 5/325 mg showed the medication was last signed out as a one-tablet dose at 9:00 PM with 57 pills recorded, while the blister pack contained 56 pills. The MAR reflected that LVN F documented administering the same medication at 9:00 AM, creating a mismatch between the MAR, the narcotic record, and the medication count. A similar issue was identified for Resident #10, whose order was for oxycodone 5 mg, 2 tablets every 6 hours as needed for severe pain. The narcotic log showed the medication was last signed out as a two-tablet dose at 9:00 PM with 94 pills remaining, while the blister pack contained 92 pills. There was no MAR documentation showing that the oxycodone had been administered. Resident #24 had diagnoses including fibromyalgia and chronic pain, with intact cognition and a BIMS score of 14. Resident #10 had diabetes mellitus, chronic pain, polyneuropathy, moderately impaired cognition, and a BIMS score of 12. During interview, LVN F stated she gave both residents the medication but forgot to document on the MAR and sign out on the NAR. She said she knew she was supposed to document the narcotic medication after administration but did not, and she could not tell when she administered the medication. She also stated she had not done training since she was newly hired. The DON stated he expected staff to follow the medication administration policy by documenting on the MAR and signing the narcotic log when narcotic medications were given, and he stated failure to do so could lead to drug diversion.
Missing physician order for droplet precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident who returned to the facility with rhinovirus. Resident #4 was a male with a BIMS score of 11 and diagnoses including hypertension, malnutrition, and diabetes mellitus. His care plan, initiated after readmission, stated that he remained on droplet precautions and included interventions to continue droplet isolation precautions as indicated, and a progress note documented that he remained on isolation for rhinovirus. However, the Order Summary Report did not reflect an order for droplet isolation precautions. Observation showed a sign posted outside the resident’s room for contact and droplet precautions, and staff interviews reflected uncertainty about the resident’s condition, how long precautions should continue, and who was responsible for obtaining the physician order. The IP stated that all orders should come from the doctor and include the timeframe and reason for droplet precautions, but she had not verified that the order was in the chart for this resident. The DON stated the resident was on droplet precautions for rhinovirus and that there should have been an order in the chart for informational purposes so staff would know why the resident was on precautions and for how long.
Failure to Ensure Proper Connection of G-Tube During Continuous Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving enteral nutrition via G-tube was properly connected to the feeding pump when the pump was turned on, resulting in tube feeding formula running onto the floor instead of being delivered to the resident. The resident was an adult female with diagnoses including type II diabetes, gastrostomy status, dysphagia (pharyngeal phase), muscle wasting/atrophy, and malignant neoplasm of the endometrium. Her comprehensive MDS showed she was dependent on staff for most ADLs, had a BIMS score of 00, and required a feeding tube for nutrition. Physician orders specified an NPO diet, continuous G-tube feeding with Diabetic Source 1.5 at 55 ml/hr for 22 hours per day with water flushes every 4 hours, and a scheduled daily downtime for the feeding. On the survey date, the resident’s care plan documented that she required tube feeding and was to remain free of side effects or complications, with interventions including following current feeding orders. Earlier that day, the resident was observed awake in bed with the enteral feeding pump running at 55 ml/hr, and from the surveyor’s vantage point there were no visible concerns at that time. Later, the resident’s responsible party (RP), who was visiting, discovered that the resident’s G-tube was not connected to the feeding pump and that formula was running onto the floor. The RP reported that the resident had not been fed for at least the past hour due to the G-tube not being connected when the pump was turned on, and provided a video showing the G-tube disconnected and clamped, with a puddle of formula on the floor while the pump was running. Subsequent observations and interviews confirmed the sequence of events leading to the deficiency. When the surveyor returned to the room, the G-tube had been reconnected and the pump was running at 55 ml/hr, but formula remained on the floor from the earlier spill. LVN A stated that she had turned off the pump between approximately 9:00 and 9:30 for the ordered downtime, flushed and clamped the tube, and then returned around 11:30 to restart the feeding but forgot to reconnect the G-tube before turning the pump back on. She attributed the error to being busy and called away to assist another resident. CNA B reported that around 12:20 she entered the room to provide care, noticed the G-tube was still clamped, and at the same time the family observed formula running from the pump onto the floor, after which LVN A was called in and reconnected the tube. The facility’s own policy on enteral tube feeding via continuous pump required ensuring equipment and devices were working properly, and staff interviews acknowledged that not reconnecting the G-tube to the pump could result in nutrition and hydration issues, confirming that the resident did not receive the ordered enteral feeding during the period when the pump was running but the tube was disconnected.
Failure to Ensure Adequate Oxygen During Resident Transport
Penalty
Summary
A deficiency occurred when a resident who required continuous oxygen therapy was not provided with adequate oxygen during a community appointment. The resident, who had a history of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, and other comorbidities, was transported to a dental appointment with a full portable oxygen tank. The appointment lasted significantly longer than expected, resulting in the resident being away from the facility for approximately five hours. During the return trip, the resident's portable oxygen tank ran out, and he began experiencing shortness of breath. Staff accompanying the resident, including a CNA, noticed the resident's respiratory distress and checked the oxygen tank, finding it nearly empty. The CNA contacted the ADON, who instructed them to pull over and call 911. Emergency medical services arrived and found the resident with an SpO2 of 50%. The resident was transported to the hospital, where he was diagnosed with acute hypoxia and acute on chronic respiratory failure with hypoxia and hypercapnia. The resident reported feeling unable to breathe and nearly blacking out before EMS arrived. Prior to the incident, the facility's procedures for oxygen administration did not address the specific needs of residents on continuous oxygen therapy during transportation outside the facility. Staff interviews confirmed that while checks were made to ensure tanks were full before departure, there was no protocol for providing an extra tank for longer appointments. The deficiency was identified as past non-compliance, with the immediate jeopardy period beginning and ending within a two-day span.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, specifically in trimming toenails, which is a part of maintaining good foot health. The resident, an elderly female with severe cognitive impairment and a terminal prognosis related to alcoholic cirrhosis of the liver, was totally dependent on staff for personal hygiene and dressing. Despite her dependency, the care plan did not address her ADL care or nail care, and she had not been seen by a podiatrist during scheduled visits. The resident expressed concerns about her long toenails, which were causing discomfort, particularly on her right foot. She reported that she had attempted to cut them herself but was unable to do so and had asked staff for assistance, only to be told that a podiatrist was needed. However, she was not seen by a podiatrist on the scheduled dates, and no referral had been made until the day of the interview. Staff interviews revealed a lack of awareness and communication regarding the resident's need for podiatry care, with the RN, CNA, Social Worker, ADON, DON, and Administrator all indicating that the resident had not mentioned her toenail issues to them. The facility's foot care policy, revised in October 2022, stated that residents should receive appropriate care and treatment to maintain foot health, with trained staff providing routine foot care for residents without complicating disease processes. However, this policy was not effectively implemented for the resident in question, leading to the deficiency noted in the report.
Failure to Address ADLs in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the care plan did not address the resident's activities of daily living (ADLs), despite the resident's severe cognitive impairment and total dependence on staff for personal hygiene and dressing, as indicated in the quarterly MDS assessment. The resident expressed concerns about her toenails, which were long and bothersome, and reported that staff had not assisted her with this issue, citing that a podiatrist was needed, who had not seen her as scheduled. Interviews with facility staff, including an RN, MDS Coordinator, and the DON, revealed that the responsibility for updating care plans lay with the MDS Coordinators and nursing staff. The MDS Coordinator acknowledged that the ADLs were not included in the care plan and admitted it was an oversight. The DON confirmed that ADLs should be part of the comprehensive care plan. The facility's policy on baseline care plans emphasized the need for instructions to provide effective, person-centered care, including necessary services and treatments, which were not adequately addressed in this case.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The deficiencies included improper hair restraint by a dietary staff member, DCH A, who was seen with a hair net that did not fully cover his hair while rolling silverware near prepared food. This lapse in personal hygiene could potentially lead to food contamination. Additionally, the facility did not ensure that food items in the dry storage area, walk-in cooler, and walk-in freezer were properly sealed, labeled, and dated. Several food items, such as pasta, beans, cubed meat, hardboiled eggs, applesauce, and a white liquid substance, were found unsecured, undated, and unlabeled. The walk-in cooler was observed to have an internal temperature of 48 degrees Fahrenheit, which is above the required 41 degrees Fahrenheit for safe food storage. The absence of an internal thermometer in the cooler was noted, and the temperature gauge outside the cooler confirmed the elevated temperature. This improper temperature control could increase the risk of foodborne illness among residents. The assistant to the Dietary Supervisor, [NAME] B, acknowledged the issues and mentioned that the dietary supervisor had removed the internal thermometer for replacement but had not yet done so. The Dietary Supervisor and the Administrator were informed of these deficiencies. The Dietary Supervisor confirmed that all opened foods should be sealed, labeled, and dated, and that saran wrap should not be used for sealing. He was unaware of the missing thermometer and the cooler's temperature issue. The Administrator stated that all foods should be properly stored and that all dietary staff should fully restrain their hair. Both acknowledged that these failures could lead to food contamination and illness among residents.
Failure to Notify Resident and Ombudsman of Transfer/Discharge
Penalty
Summary
The facility failed to provide timely written notification to a resident, her representative, and the Ombudsman regarding her transfer and discharge to a hospital for behavioral reasons. The resident, who had moderate cognitive impairment and a history of encephalopathy, legal blindness, acute respiratory failure, and schizophrenia, was transferred to the VA Hospital due to escalating mental health concerns. The facility did not document the notification of the resident, her responsible party, or the Ombudsman in writing about the discharge or the reasons for it. Interviews revealed that the resident's POA was informed verbally about the transfer and discharge but did not receive any written documentation. The facility administrator confirmed that the resident was transferred for a mental health assessment and stabilization due to combative and verbally aggressive behavior. However, he was unaware of the requirement to notify the Ombudsman in writing for discharges other than those involving a 30-day notice. The facility's policy required written notification to the resident, representative, and Ombudsman, which was not followed in this case.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident rooms were equipped with privacy curtains that assured full visual privacy for 11 out of 53 rooms. Specifically, rooms 201, 202, 205, 207, 211, 302, 305, 306, 307, 406, and 409 lacked privacy curtains for residents in the A beds, which could expose residents to the hallway during care. An observation revealed that LVN C and CNA D did not provide full visual privacy for a resident during care, as the door to the hallway popped open slightly, and there was no privacy curtain around the resident's bed. Interviews with staff, including the DON and the Administrator, confirmed that they were unaware of the lack of appropriate privacy curtains and acknowledged the dignity issue this posed for residents. The report highlights a specific incident involving a resident with severe cognitive impairment and a high fall risk, who required total assistance with activities of daily living. During a skin assessment, the resident's privacy was compromised when the door to the hallway opened slightly, and there was no privacy curtain to prevent exposure. The facility did not have a policy addressing privacy curtains specifically, and the staff relied on closing doors and verbal warnings to maintain privacy, which were insufficient to prevent exposure during care.
Infection Control Breach Involving Housekeeper's Handling of Food
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a housekeeper's inappropriate handling of food. A housekeeper, identified as Housekeeper A, was observed picking popcorn off the floor and placing it back into a resident's bag of popcorn, which was later consumed by the resident. This action was captured on video footage reviewed by the resident's family, who subsequently reported the incident to the facility's Administrator. The resident involved was an elderly male with a history of pelvic fracture, falls, and dementia, and had a BIMS score indicating mild cognitive impairment. The incident was corroborated by another housekeeper, Housekeeper B, who witnessed the event but misunderstood Housekeeper A's intentions, believing the entire bag would be discarded. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance.
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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 Hurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Emerald Hills | 2.4 mi | ★★★★★ | 20 | 0 |
| Bedford Wellness & Rehabilitation | 2.8 mi | ★★★★★ | 16 | 0 |
| La Dora Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 6 | 0 |
| Hurst Plaza Nursing And Rehab | 2.9 mi | ★★★★★ | 6 | 0 |
| Keller Oaks Healthcare Center | 3.2 mi | ★★★★★ | 4 | 0 |
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